Coronary stent implantation in elderly patients: acute and long-term results

The number of elderly patients with coronary heart disease is rapidly growing. Morbidity, related with PTCA is increased in elderly patients, presumably because of the more complex adverse baseline characteristics. However, it has not been firmly elucidated whether routine use of coronary stents is associated with a more favourable outcome in this population. Therefore, we investigated the influence of age on acute procedural success, rate of restenosis (quantitative coronary angiography) and major cardiovascular events (death/myocardial infarction [MI]) 6 months after intra-coronary stent implantation in 1306 patients. Patients were categorised into < 65 years (n = 709),65-75 years (n = 443) and >75 years (n= 154). RESULTS: Older patients had a higher amount of multivessel disease (p < 0.001) and a lower left ventricular ejection fraction (p < 0.001). Nevertheless, the rate of acute success and restenosis were comparable between the different age groups. In contrast, older patients had significantly more adverse clinical events during long-term followup. (Death/MI < 65 years 3.0%, 65-75 years 3.9%, > 75 years 7.8%, p = 0.02). However, by multivariate analysis age was no longer an independent predictor of adverse clinical events (p = 0.26), which were predominantly determined by coexisting impaired left ventricular function (p < 0.001). CONCLUSION: After proper judgement of the clinical situation, coronary stent implantation should be considered in selected elderly patients. Thus, advanced age as a solely factor should not be regarded as a contraindication for coronary stent implantation.     

Coronary artery surgery in the elderly: long-term follow-up

Background: There has been controversy concerning the indications for coronary artery surgery in the elderly, particularly in countries where health resources are restricted.
Aims: To assess the results of coronary artery bypass grafting (CABG) in a large group of elderly subjects with regard to initial risks and long term follow-up.
Methods: Ninety-six consecutive patients aged 70 years or older underwent isolated CABG between January 1981 and December 1985. Long term follow-up was obtained in 94 (98%).
Results: The mean age was 71.6 years (70–78) and mean duration of follow-up 73 months. Seventy (73%) were male. In 80 cases the myocardial score was > 10. In 22 of 90 who had left ventricular angiography the ejection fraction was < 50%. Hospital survival was 96% and the five year survival 77%. It was not influenced by gender, myocardial score, ejection fraction or age at the time of operation. The status of survivors was reviewed in 1991. Of the 55 long term survivors 35 (64%) were free of angina. Eight (15%) and ten (18%) were in the Canadian Cardiovascular Society Angina classes 1 and 2 respectively. Seventeen patients (31%) had symptoms of heart failure with 14 (25%) in NYHA class 2 and 3 (5%) in class 3. Eight patients (15%) had survived a cerebrovascular event during follow-up. There were 35 late deaths (37%). Sixteen of these were cardiac, 18 due to other causes and one unknown. (Aust NZ J Med 1993; 23: 489–493.)     

Coronary artery bypass surgery in elderly patients

Seventy-five patients 65 years of age and older had coronary artery bypass surgery during 2 years at Scott and White Memorial Hospital with a 4 per cent mortality rate. An average of 3.1 grafts were placed and 5.1 units of blood were used during 13 days of postoperative hospitalization. Sixty-one patients were in New York Heart Association Class IV, 12 were in Class III, and 2 had other indications for coronary artery bypass. One year following surgery there were 60 patients in Class I, 6 in Class II, 3 in Class III, and 1 in Class IV; 1 patient was dead, and 4 were lost to follow-up. Our conclusion is that coronary artery bypass grafting can be performed with an acceptable mortality rate in the elderly and that age alone should not be considered a contraindication to the operation.     

Primary percutaneous coronary interventions in acute myocardial infarction in diabetic versus non-diabetic patients. In-hospital and long-term results

BACKGROUND. It has been well established that in the pre-thrombolytic era diabetic patients had poorer clinical outcome after acute myocardial infarction (AMI) compared to non-diabetic patients. Less is known about the impact of diabetes on early and late clinical outcomes in patients with AMI undergoing primary percutaneous coronary interventions (PCI). AIM. To compare the in-hospital and long-term clinical outcomes of AMI patients with and without diabetes. METHODS. Seven hundred seventy-four patients who underwent primary PCI for AMI in our institution between 1997 and 2001 were included in the study. We compared the angiographic and clinical outcomes of 633 (81.8%) non-diabetic (aged 55.9+/-10.6 years; 82.6% male) and 141 (18.2%) diabetic (aged 56.8+/-11.7 years; 63.1% male) patients. RESULTS. Diabetic patients had a higher incidence of hypertension, hyperlipidemia, and unstable hemodynamic status compared to non-diabetic patients (p=0.001, 0.003, 0.001, respectively). Smoking and male gender rates were significantly more frequent in non-diabetic patients (p=0.001, 0.001, respectively). Angiographic success and prominent clinical improvement were achieved in 96.4% and 90.7% of diabetics vs 96.7% and 95.1% of non-diabetics (p=NS and 0.04, respectively). Diabetic patients had a higher incidence of in-hospital deaths and overall events (p=0.028). At one-month follow-up, diabetic patients required more target vessel revascularisation (5.6% vs 1.6%; p=0.006), which accounted for the majority of major cardiac events at one month (20.6% vs 7.4%; p=0.003). At a mean follow-up of 7.2+/-2.7 months, 92.9% of non-diabetic and 88% of diabetic patients were still alive (p=0.05). Overall survival without any major cardiac event (death, new MI or target vessel revascularisation) at 7.2+/-2.7 month follow-up was 75.8% for non-diabetics and 58.1% for diabetic patients (p<0.01). In the multivariate analysis age, diabetes, shock, hemodynamic instability and female gender were the most important predictors for the development of early and late major cardiovascular events. CONCLUSIONS. Primary PCI in acute MI is effective in restoring TIMI 3 coronary flow both in diabetic and non-diabetic patients. This procedure may reduce mortality in both groups, particularly in diabetic patients in whom this benefit is more prominent compared to thrombolytic therapy. Nevertheless, early and long-term event rates are significantly higher in diabetics than in non-diabetic patients.     

Coronary stents in patients with severe left ventricular dysfunction. Hospital and long-term results

The aim of this study was to evaluate the risks and benefits, immediate and at long term, of coronary angioplasty associated with stent implantation in patients with severe left ventricular dysfunction. It was a retrospective study in which all patients with left ventricular ejection fractions 35% who underwent angioplasty between December 1994 and January 1998 were included. Seventy eight patients with an average ejection fraction of 29 +/- 6% who were haemodynamically stable were retained, excluding acute myocardial infarctions and cases of cardiogenic shock. The population was mainly masculine (6(men and 13 women) with a mean age of 65 +/- 11 years. The primary success rate was 97%. The loss of a collateral branch during the procedure, causing a non-Q wave infarction and the impossibility of implanting the stent at the desired site in another patient, were the only two failures. Hospital mortality was nil. The mean follow-up period was 450 +/- 290 days; long-term mortality was 17%. All deaths were of cardiovascular origin. The probability of survival at 6 months, 1 year and 800 days, was 88, 85 and 75% respectively. The good initial results were not maintained at long-term, but this could not be attributed to restenosis or to the pre-existing left ventricular dysfunction.     

Mitral valve surgery in elderly patients]

The increase in life expectancy results in a larger number of elderly patients with mitral valve pathology requiring surgical correction. Generally speaking, the indications for surgery are identical to those which apply to other age groups, but the greater incidence of mortality and, especially, of morbility make a degree of selectivity advisable. More than with any group, it is important to consider the risk: benefit ratio. However, in the majority of cases, it is possible to optimise the clinical condition of the patients with a significant decrease in risk. One of the most controversial aspects is that of the advantages or disadvantages of mitral valvuloplasty vs. prosthetic replacement. Although the eventual lower durability of the valvuloplasty might be considered a contraindication, because of the risk of reintervention at a later age, I believe that valvuloplasty is also preferable in elderly patients. This is confirmed by the well known fact that mitral valvuloplasty for myxomatous mitral regurgitation, prevailing in this age group, has the most durable results among all types of pathology. In the last 10 years, 433 patients above 70 years of age (11.6% of the total) were subjected to valvular surgery in Coimbra. Valvuloplasty was possible in more than 90% of the cases of mitral valve surgery. The mortality was only 2.6%, but significantly higher than that observed in younger patients (0.8%). In conclusion, mitral valve surgery in elderly patients is feasible with acceptable mortality and morbidity, but pre-operative optimization of the patients is essential.     

In-hospital Acquired Anemia in Acute Coronary Syndrome. Predictors, In-hospital Prognosis and One-year Mortality

INTRODUCTION AND OBJECTIVES: Anemia at hospital admission predicts a poor outcome in patients presenting with acute coronary syndrome. It remains unclear whether in-hospital hemoglobin levels decrease (nosocomial anemia) not related to bleeding also implies a poor prognosis. We aimed to identify predictors of nosocomial anemia and its prognostic significance. METHODS: We prospectively included 221 acute coronary syndrome patients admitted in our institution during the years 2009-2010, with normal hemoglobin levels at admission. Nosocomial anemia was defined as a decrease in hemoglobin levels to <13?g/dL in men and <12?g/dL in women in the absence of apparent bleeding. Clinical variables and hematological inflammatory parameters were assessed in order to identify predictors for the development of nosocomial anemia. We compared the clinical outcome after a 1-year follow-up period of patients without anemia as opposed to those who developed nosocomial anemia. RESULTS: Nosocomial anemia was registered in 25% of study patients. A >3.1mg/dL value of C-reactive protein was highly predictive of developing nosocomial anemia (odds ratio=5.9; 95% confidence interval, 2.6-13.4; P<.001). The incidence of mortality and cardio-vascular morbidity was higher in the patients who developed nosocomial anemia (34.5% vs 9%; P<.001). Nosocomial anemia was a strong predictor of cardio-vascular morbidity and mortality in the long-term follow-up (hazard ratio=2.47; 95% confidence interval, 1.23-4.96; P=.01). CONCLUSIONS: Nosocomial anemia predicts a poorer outcome in patients with acute coronary syndrome. Increased C-reactive protein levels, indicating inflammatory state, are predictive of developing in-hospital anemia unrelated to apparent bleeding. Full English text available from:www.revespcardiol.org.     

Coronary artery bypass surgery provides long-term results superior to percutaneous coronary intervention

Traditionally, patients presenting with symptoms of coronary artery disease (CAD) were managed medically. If medical treatment proved unsuccessful, patients were referred for coronary artery bypass surgery (CABG). However, in recent years, increasing numbers of patients have received percutaneous coronary intervention (PCI), usually a coronary stent, for primary treatment. PCI is attractive because it is minimally invasive, has proven success in the immediate treatment of acute myocardial infarction and is well-accepted for poor surgical candidates in selected cases. However, evidence from emerging and ongoing clinical trials and registries suggests that compared to PCI, CABG offers superior long-term prognostic benefits in many, if not most, patients with significant CAD. We present an analysis of recent evidence showing that patients with complex atherosclerotic lesions, multivessel disease, left main stem disease, left ventricular dysfunction and diabetes mellitus derive more benefit from surgical revascularisation than from PCI. We conclude that PCI should be restricted to patient groups where superiority or equivalence to CABG has been demonstrated and that the decision-making process in allocating treatment should be made by a multidisciplinary team to ensure that every patient receives balanced advice and therapy that is most effective in the long term.     

Immediate and long-term results of coronary surgery under age 40]

The results of coronary artery surgery in young adults have not been extensively studied. We analysed the results of 221 patients under 40 years of age operated between 1979 and 1989 at the Pitié-Salpêtrière Hospital. The patients were 200 men and 21 women with an average age of 36.2 years. The most common cardiovascular risk factors were smoking (69.6%) and hyperlipidaemia (52%). One hundred and eighteen patients (53.4%) had previous myocardial infarction (MI). Triple vessel disease was present in 129 cases, double vessel disease in 59 cases and single vessel disease in 33 cases. Twenty three patients had significant left main coronary disease. The number of bypass grafts per patient averaged 2.3. The operative mortality was 2.07% (6 cases), death being due to myocardial infarction in 4 cases. Perioperative myocardial infarction was diagnosed in 12 cases (5.05%). One hundred and ninety nine patients were followed up for an average of 7.4 years. Seven of the 17 late fatalities were of cardiac origin. The actuarial 9 year survival rate was 84%. Five patients were reoperated after an average of 6.4 years. Eighty five per cent of patients were asymptomatic at the last follow-up examination. In conclusion, the symptoms of coronary artery disease in young adults can be effectively treated with a low operative risk by myocardial revascularisation surgery. Long-term follow-up remains essential to define the outcome in these patients. Systematic use of internal mammary artery bypass grafting should improve these results in the future.     

Aneurysmectomy and aortocoronary bypass. Immediate and long-term results of 56 patients]

56 pts. who underwent left ventricular aneurismectomy were studied. Clinical improvement and lat post-operatory mortality rate have been evaluated. 39 pts. (II group) also had aortocoronary bypass and other surgical procedures performed at the time of the aneurismectomy. Group I (no other surgery beside the aneurismectomy) and group II did not significant differences in the pre-operatory period and were, therefore, comparable. The total operatory mortality has been of 14% (17.6% in group I and 12.8% in group II). By using myocardial protection the mortality dropped to 5.8%. A significant difference between deceased and survived pts. was noted in the following parameters: cardiac index, A-V oxygen difference, extracorporeal circulation time and the number of diseased coronary arteries (P < 0.001-0.005). Only 2 pts., both in group II, had a late death. After the operation 32 pts. became asymptomatic. Five pts. remained symptomatic: 3 continued to complain of angina and 2 to show signs of left ventricular failure; ventricular arrhythmias were still present in 6 pts. post-operatively (compared to 16 pts. pre-op.). The data suggested that aneurismectomy, associated with aorto-coronary bypass and myocardial protection, has an acceptable operatory risk, particulary in pts. with a good residual ventricular function. Except for ventricular arrhythmias clinical results are very good and late mortality rate is low     

Coronary surgery. Developments in the last decade. Indications and results

Coronary artery bypass surgery is endorsed by the excellent, well-documented, long-term results that follow complete revascularization and the use of 1 or 2 mammary artery grafts. This article contains a review of the current indications for and the results of such surgery and an evaluation of new challenges and opportunities, including the implementation of safer and less aggressive surgery, and surgery associated with other operative procedures. The aim was to develop a strategy linked to a cycle of innovation that could be used to adapt surgery to the needs of the population, to new technologies, and to pioneering developments.     

Coronary and valvular surgery in elderly patients (greater than 70 years)

During 1949-1964 only 22% of our patients (n = 6807) undergoing cardiac surgery were older than 40 years. Up to 1970 no patients older than 60 years underwent open-heart surgery in our institution. Between 1970 and 1978 an open-heart procedure was performed in 174 patients older than 60 years (4.5%). The hospital mortality was 18.3%. During the following years the operative indication for aged patients became more liberal, and the operative risk decreased distinctly. Already in 1983 the percentage of aged people rose to 24.1% of our extracorporeal circulation group (n = 1111). In a retrospective study (1979 to 1985) a total of 6855 heart procedures using ECC were evaluated. In total 196 patients (2.9%) were 70 years and older. Valvular replacement was performed in 95 cases. (AVR n = 67, MVR n = 13, DVR n = 15) resulting in a hospital mortality of 10.9% (n = 10). Revascularisation for coronary heart disease including resection of ventricular aneurysms was necessary in 64 patients with an early mortality rate of 3.1% (n = 2). The highest risk group consisted of combined coronary and valvular procedures (n = 33) with a mortality rate of 12.1% (n = 4). There was one case each of ASD II, HOCM, left atrial myxoma, and massive pulmonary embolism with cardiogenic shock: only the latter patient died, from cerebral hypoxia postoperatively. Thus the hospital mortality in this age group (n = 196) was 9.1% (n = 17).(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary angioplasty in the elderly patient. Immediate results and mid-term outcome

Between April 1980 and July 1986, 50 patients over 65 (32 men and 18 women; mean age: 72 years) were treated by transluminal coronary angioplasty. Before the dilatation, 58 p. cent of the patients presented a severe angor (class III or IV) and 44 p. cent were multi-truncular. The dilatation was successful in 39 patients (78%) and 13 patients developed a recurrent stenosis successfully treated in 9 instances by re-dilatation. Among the complications, there were 2 deaths (4%), 3 infarctions (6%) and 3 emergency coronary bypass operations (6%). With a mean 28 months follow-up, the overall survival is 92 p. cent. After a successful dilatation, 49 p. cent of the patients are completely asymptomatic and the subsequent cardiological hospitalizations are rare (11%). These results show that coronary dilatation represents an interesting therapeutic option in elderly coronary patients.     

In-hospital referral source and rehabilitation outcome of elderly stroke patients

To date, there is no data regarding the association of patient in-hospital referral source and stroke rehabilitation outcomes. The objective of the present study was to investigate the possible relation between in-hospital referring source, whether directly from an emergency ward (EW) or indirectly through a general medical ward (GMW), and the functional outcomes achieved during rehabilitation of such stroke patients. This retrospective observational study included 315 consecutive patients, admitted for rehabilitation following the onset of acute stroke. We compared those referred directly to us from the EW, with others referred from GMWs. Functional status was assessed by Functional Independence Measure method (FIM). Functional outcome was determined by total FIM gain (efficacy) and daily FIM gain (efficiency), both absolute and relative (to potential). The two study groups were similar in terms of age, gender, and diagnosis. FIM admission scores were higher at admission in patients admitted directly from the EW, compared with those referred from GMWs (72.5 +/- 27.5 and 62.7 +/- 25.6, respectively) but similar at discharge (77.4 +/- 28.8 and 80.7 +/- 32.5, respectively). Length of stay (LOS) in the GMW group was longer as compared to the EW group. Efficacy was significantly associated with being married, younger age, hemiplegia, and admission scores between 40-60. Both absolute and relative efficacy and efficiency rates of rehabilitation were significantly lower among patients referred from the EW. We conclude that in-hospital referral source is associated with different rehabilitation outcomes in stroke patients. Direct admission of stroke patients from the EW is associated with lower rehabilitation efficacy and efficiency rates, compared with those admitted from GMWs. The findings support the implementation of different selection methods, underscoring the need of both clinicians and administrators to consider the in-hospital referral source as a potential factor associated with stroke rehabilitation outcome.     

The long-term results of aortocoronary bypass surgery in patients with a severe preoperative left ventricular dysfunction]

We analyze retrospectively the short- and long-term results of coronary artery bypass surgery in 50 patients with severe left ventricular dysfunction operated in a period of 11 years. Sixty-six percent of patients had unstable angina and 12% of total presented angina post-acute postmyocardial infarction. Thirty-eight percent of patients were in preoperative functional class III-IV of NYHA. Three-vessel disease was present in 70% of the patients, two-vessel in 30%, and the main trunk was affected in 12% of the global. Hospital mortality was 4% (2/50) due to low cardiac output syndrome. Follow-up was available in all the survivors and ranged 6 months-11 years (mean: 4.8 +/- 3.1). During follow-up, 13 patients died, but in only six was due to cardiac cause. The 35 patients followed were in functional class I-II of NYHA. Eighty-eight percent of the patients were angina free at follow-up. Actuarial analysis, after exclusion of 3 patients who died of causes no directly related to the heart, showed an intrahospital survival rates of 96%; at first year was 92, at 3rd was 78%, and 5th year survival rates were 75%. In conclusion, patients with symptomatic angina and preoperative severe left ventricular dysfunction, coronary artery bypass graft has a low hospital mortality, is effective in improving angina and heart failure, and the long-term survival is acceptable.     

Emergency coronary surgery after transluminal angioplasty. Immediate results and long-term outcome of 100 operations]

The increasing application of percutaneous transluminal coronary angioplasty (PTCA) requires evaluation of emergency coronary artery surgery for complications of this procedure. In a consecutive series of 2,576 angioplasties performed between April 1980 and January 1990, 100 patients (82 men and 18 women, average age 54 +/- 10 years, 3.9%) underwent emergency coronary artery surgery because of complications. The artery involved was the left anterior descending artery in 81% of cases. The causal lesion was a dissection and/or thrombus in 95% of cases; 85% of patients were referred for surgery with acute myocardial infarction. The average delay before surgery was 110 +/- 15 minutes (interval between coronary occlusion and starting cardiopulmonary bypass) and 155 coronary grafts were implanted (1.5 per patient). The hospital mortality was 19%; the infarction rate was 57%. The left ventricular ejection fraction decreased from 63 +/- 10% (preoperatively) to 52 +/- 9% (postoperatively), p less than 0.001. Hospital mortality was significantly related to three factors, old age, unstable angina before PTCA, and cardiogenic shock or the necessity for external cardiac massage. In the subgroup of patients developing cardiogenic shock (n = 7) or requiring external cardiac massage during transfer to the operating theatre (n = 16) the mortality was 44%. Among the 81 survivors, the global 7 year survival rate was 96% (Kaplan-Meier) with 3 cardiac deaths, 2 other patients developing myocardial infarction and 4 undergoing repeat angioplasty. After an average follow-up of 55 +/- 38 months, 80% of patients are asymptomatic, 34% have no antianginal drugs and 73% of those who were previously employed have returned to work.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac surgery in octogenarians; peri-operative outcome and long-term results.

AIMS: Because the elderly are increasingly referred for operation, we reviewed the results of cardiac surgery in patients of 80 years or older. METHODS AND RESULTS: Records of 182 consecutive octogenarians who had had cardiac operations between 1992 and 1998 were reviewed. Follow-up was 100% complete. Seventy patients had coronary grafting (CABG), 70 aortic valve replacement, 30 aortic valve replacement+CABG, and 12 mitral valve repair/replacement. Rates of hospital death, stroke, and prolonged stay (>14 days) were as follows: CABG: 7 (10%), 2 (2.8%) and 41 (58%); aortic valve replacement: 6 (8.5%), 2 (2.8%) and 32 (45.7%); aortic valve replacement+CABG: 8 (26.5%), 1 (3.8%) and 14 (46.6%); mitral valve repair/replacement: 3 (25%), 1 (8.3%) and 5 (41.6%). Multivariate predictors (P<0.05) of hospital death were New York Heart Association functional class, urgent procedure, prolonged cardiopulmonary bypass time, and, after aortic valve replacement, previous percutaneous aortic valvuloplasty. Ascending aortic atheromatous disease was predictive of stroke, while pre-operative myocardial infarction was predictive of prolonged hospital stay. Actuarial 5-year survival was as follows: CABG, 65.8+/-8.8%; aortic valve replacement, 63.6+/-7.1%; aortic valve replacement+CABG, 62.4+/-6.8%; mitral valve repair/replacement, 57.1+/-5.6%; and total, 63.0+/-5.6%. Multivariate predictors of late death were pre-operative myocardial infarction, and urgent procedure. Ninety percent of long-term survivors were in New York Heart Association class I or II, and 87% believed having a heart operation after age 80 years was a good choice. CONCLUSION: Cardiac operations are successful in most octogenarians with increased hospital mortality, and longer hospital stay. Long-term survival and quality of life are good.