Reperfusion strategies for acute myocardial infarction in the elderly: benefits and risks

The optimal reperfusion strategy in elderly patients with ST-segment elevation myocardial infarction (STEMI) remains a topic of debate. This lack of consensus stems from the exclusion or under-representation of the elderly in clinical trials. This review evaluates the available literature pertaining to reperfusion therapy for the treatment of STEMI in the elderly. We identified all published studies evaluating the effectiveness of thrombolytic therapy, primary percutaneous coronary intervention (PCI), or adjunctive therapies to reperfusion by conducting an electronic search of MEDLINE through December 2003. Meta-analysis of clinical trials suggests a survival benefit of thrombolytic therapy in the elderly with STEMI, whereas some observational studies have raised concerns about the lack of short-term benefit or possibility of harm with thrombolysis. However, most observational studies demonstrate improved intermediate-term survival with thrombolysis. In contrast, multiple clinical trials and observational studies indicate improved survival and low risk of stroke with primary PCI compared with thrombolysis in elderly patients with STEMI. Information on the efficacy of newer antithrombotic agents as adjunct to thrombolysis or primary PCI is scarce. Available data suggest an increased risk of intracerebral bleeding with the combination of a fibrin-specific agent and a glycoprotein IIb/IIIa receptor antagonist in patients >75 years of age. Clearly targeted large-scale clinical trials are needed to evaluate the relative merits of available reperfusion strategies as well as newer antithrombotic adjunctive therapies in the elderly with STEMI.     

Optimal revascularization strategies for ST-segment elevation myocardial infarction in the elderly patient

Patients older than 75 years account for >60% of all deaths from acute myocardial infarction. Although there are accepted guidelines for treatment of acute ST-segment elevation myocardial infarction, elderly patients tend to have a variety of conditions that can complicate decisions about the best therapy. Many elderly patients do not receive potentially lifesaving treatments, such as percutaneous coronary intervention or thrombolytic therapy, for fear of an adverse event. Those who do receive appropriate revascularization therapy often receive it later in the course of the infarct, when irreversible damage has occurred. Yet studies show that patients older than 75 years will benefit substantially from these therapies. Early treatment improves outcomes in this population, as in younger patients, despite a higher risk of complications. In this review, the evidence regarding medical and revascularization therapies in ST-segment elevation myocardial infarction is critically examined.     

Epidemiology, clinical features, and prognosis of acute myocardial infarction in the elderly

The incidence and prevalence of acute myocardial infarction (MI) increase progressively with age. In the United States, over 60% of acute MIs occur in patients 65 years of age or older, and approximately one third occur in persons over age 75. In addition, mortality rates following acute MI increase exponentially with age, such that approximately 60% of all MI deaths in the United States occur in the 6% of the population 75 years of age or older. The clinical features of acute MI vary by age. In particular, very elderly patients are less likely than younger patients to report chest pain. Conversely, confusion or altered mental status may be the presenting manifestation of acute MI in up to 20% of patients over 85 years of age. Older patients are also more likely to have "silent" or unrecognized MIs, as well as MIs without ST-segment elevation, compared with younger patients. Elderly patients with acute MI are more likely than younger patients to experience heart failure, atrial fibrillation, cardiac rupture, and shock, all of which are associated with increased mortality. Other factors contributing to the poor prognosis following acute MI in elderly individuals include a marked decline in cardiovascular reserve in the elderly, increased prevalence of comorbid conditions, underutilization of evidence-based therapies, and increased risk of iatrogenic complications.     

老年人脑肿瘤163例临床分析

目的 探讨老年人脑肿瘤的临床特点，以期提高对老年脑肿瘤患者的临床救治质量。方法 回顾性分析经CT、MRA或病理证实的老年颅内肿瘤患者163例的临床资料。结果 肿瘤位于幕上121例，以脑膜瘤（68例）、胶质瘤（43例）常见；129例并存其他疾病；手术后症状消失或明显改善126例，轻度改善19例，无改善6例。术后1个月内死亡12例（其中住院期间死亡10例，出院后死亡2例），手术死亡率6．1％，其中〉75岁者9例。结论 认识老年脑肿瘤患者起病和病程的不典型性，对于防止临床误诊、误治有重要意义；围手术期的处理对其预后至关重要，手术治疗及临床用药应个体化。     

Effectiveness and safety of antithrombotic strategies in elderly patients with acute myocardial infarction

BACKGROUNDElderly patients represent a rapidly growing part of the population more susceptible to acute coronary syndromes and their complications. However, literature evidence is lacking in this clinical setting. AIMTo describe the clinical features, in-hospital management and outcomes of “elderly” patients with myocardial infarction treated with antiplatelet and/or anticoagulation therapy.METHODSThis study was a retrospective analysis of all consecutive patients older than 80 years admitted to the Division of Cardiology of St. Andrea Hospital of Vercelli from January 2018 to December 2018 due to ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI). Clinical and laboratory data were collected for each patient, as well as the prevalence of previous or in-hospital atrial fibrillation (AF). In-hospital management, consisting of an invasive or conservative strategy, and the anti-thrombotic therapy used are described. Outcomes evaluated at 1 year follow-up included an efficacy ischemic endpoint and a safety bleeding endpoint.RESULTSOf the 105 patients enrolled (mean age 83.9 ± 3.6 years, 52.3% males), 68 (64.8%) were admitted due to NSTEMI and 37 (35.2%) due to STEMI. Among the STEMI patients, 34 (91.9%) underwent coronary angiography and all of them were treated with percutaneous coronary intervention (PCI); among the NSTEMI patients, 42 (61.8%) were assigned to an invasive strategy and 16 (38.1%) of them underwent a PCI. No significant difference between the groups was found concerning the prevalence of previous or in-hospital de-novo AF. 10.5% of the whole population received triple antithrombotic therapy and 9.5% single antiplatelet therapy plus oral anticoagulation (OAC), with no significant difference between the subgroups, although a higher number of STEMI patients received dual antiplatelet therapy without OAC as compared with NSTEMI patients. A low rate of in-hospital death (5.7%) and 1-year cardiovascular death (3.3%) was registered. Seven (7.8%) patients experienced major adverse cardiovascular events, while the rate of minor and major bleeding at 1-year follow-up was 10% and 2.2%, respectively, with no difference between NSTEMI and STEMI patients.CONCLUSIONIn this real-world study, a tailored evaluation of an invasive strategy and antithrombotic therapy resulted in a low rate of adverse events in elderly patients hospitalized with acute myocardial infarction.     

Epidemiology and risk factors for heart failure in the elderly

Heart failure is a common problem in the elderly population, affecting 10% or more of persons more than 80 years of age. Heart failure is most likely to develop in the elderly population, with an annual incidence of 20 to 30 cases per 1000 persons aged more than 80 years. Heart failure is not only common in the elderly population but also commonly fatal, with fewer than 30% of elderly persons surviving 6 years after their first hospitalization for heart failure. Common risk factors leading to heart failure include coronary heart disease, systolic hypertension, and diabetes mellitus. The global aging of the population will perpetuate the epidemic of heart failure into the next century.     

老年人群阻塞性睡眠呼吸暂停与无症状脑梗死的相关性

目的：探讨老年人群阻塞性睡眠呼吸暂停综合征（obstructivesleepapneasyndrome, OSAS）与无症状脑梗死（silent brain infarction, SBI ）的相关性。方法筛查1658名60岁以上北京和青岛老年受试者,利用多导睡眠监测仪（polysomnography, PSG ）进行OSAS诊断和分级,利用MRI检查诊断SBI。结果在所有老年受试者中,OSAS 患病率为32.1％,SBI患病率为22.4％。不同严重程度的O S AS患者与对照组合并高血压及糖尿病的患者构成比以及睡眠呼吸暂停低通气指数（apnea-hypopnea index, AHI ）、氧减指数（oxygen desaturation index, ODI ）、平均血氧饱和度和最低血氧饱和度存在显著性统计学差异。随着OSAS严重程度的增高,SBI发生率显著增高,非OSAS 患者以及轻度、中度和重度OSAS患者的SBI发生率分别为13.2％、30.5％、43.5％和68.8％,组间存在显著性统计学差异（χ2=13.365,P=0.004）。多变量logistic回归分析显示,高血压[优势比（odds ratio, OR）2.254,95％可信区间（confidence interval, CI）1.325~8.347;P=0.002]、糖尿病（OR 1.893,95％CI 1.471~8.432;P=0.003）和AHI≥15次/h （ OR 3.106,95％CI 1.583~12.571;P<0.001）为老年人群存在SBI的独立危险因素。结论60岁以上老年人群的OSAS发生率较高,OSAS 患者的SBI发生率显著高于非OSAS患者,而且随着OSAS 的加重呈递增趋势。中到重度OSAS为老年人群S BI的独立危险因素。     

Epidemiology of diseases and handicaps in the elderly

In order to obtain valid information on incidence and prevalence of diseases and disabilities in elderly patients, careful cross sectional and longitudinal studies have to be performed. For valid information, the method of comprehensive geriatric assessment must be used which includes test for physical, mental, and social functions. Information from such studies is needed for prevention, treatment, and rehabilitation, as well as for health policies in the 1990. Although per capita health expenditure peaks in old age, presently "geriatric epidemiology" does not exist in Germany.     

Epidemiology of community-acquired pneumonia in the elderly

The attack rate for pneumonia increases with increasing age and with residence in a nursing home. The rate of hospitalization of Halifax County, Nova Scotia, Canada, residents with pneumonia was 1 in 1,000, while for nursing home residents it was 33 in 1,000. The overall mortality rate for community-acquired pneumonia requiring hospitalization was 21.9%. Mortality was age-related: Seven percent of those 30 years of age or younger died, while 38% of those in the 81 to 90 year age group died. Comorbidities increased with increasing age from 0.73 +/- 0.81 for those 30 years old or younger to 2.75 +/- 1.47 for those 71 to 80 years of age. The most common comorbidities were chronic obstructive pulmonary disease, ischemic heart disease, hypertension, diabetes mellitus, malignancy, alcoholism, and neurological disease. The acquired immunodeficiency syndrome was a significant comorbidity among those 50 years of age or younger. Age-dependent trends were observed in the use of antimicrobial therapy: Cefamandole and aminoglycosides were prescribed more frequently with increasing age, whereas after the age of 61 years, the use of erythromycin declined. Penicillin usage was not age-dependent. Resource (hemograms, chest radiographs, blood chemistry, blood gases, and sputum culture) use peaked at the 50 to 60 year age group.     

老年人支气管哮喘的流行病学

老年人支气管哮喘是一个全球性的严重的健康问题.随着全球人口老龄化和65岁以上人群的不协调增加,未来几十年老年人哮喘的数量将进一步增加.2030年全球老年人口将在20%(英国)～36%(中国)之间[1].据美国疾病防治中心(CDC)估计,美国老年人哮喘的人数在2010、2030年将分别增至2 736 572人、4 858 836人.     

老年共病管理的临床挑战与应对策略

当前我国已经进入老龄化社会,老年共病发生率逐年递增,共存疾病的数量和复杂性也随着年龄的增长而增加。而目前的临床诊治和研究主要集中于单一疾病的管理,很少关注共病带来的复杂性问题。本文重点回顾了老年共病管理的新理念、临床多学科诊疗决策、老年共病领域的挑战性问题和研究热点等,针对老年共病管理提出应对策略。     

影响老年急性心肌梗死患者再灌注治疗因素

目的 初步探讨影响老年急性心肌梗死(AMI)患者再灌注治疗的因素.方法 入选338例老年(≥65岁)AMI患者,根据是否接受溶栓或经皮冠状动脉介入治疗(PCI)分为再灌注(252例)和未再灌注(86例)两组,采用χ2检验、多因素logistic回归分析等统计方法.结果 74.6%的患者接受了再灌注治疗(其中62.2%接受PCI,12.4%接受溶栓治疗).多因素分析表明,年龄≥75岁(OR=0.255,P=0.000)、既往有心绞痛病史(OR=0.570,P=0.016)和发病时Killip分级较高(OR=0.671,P=0.012)是影响老年AMI患者较少接受再灌注治疗的因素,而下壁心肌梗死(MI)合并右室MI(OR=4.585,P=0.002)、出大汗(OR=1.970,P=0.016)、症状不能忍受(OR=1.836,P=0.038)和有医疗保险(OR=1.968,P=0.029)的患者更多接受了再灌注治疗.与溶栓治疗相比,PCI组颅内出血(2.8%比7.1%,P=0.000)、左心室射血分数<45%(12%比31%,P=0.016)、1年内病死率(2.3%比4.7%,P=0.039)明显降低.结论 高龄、心绞痛病史、Killip分级、下壁合并右室MI、出汗、症状不能耐受、有医疗保险等是预测老年AMI患者是否接受再灌注治疗的独立变量.     

高血压前期的流行趋势与管理策略

根据美国国家高血压预防、监测、评估和治疗委员会第七次报告(JNC7),收缩压120 ～ 139 mm Hg和(或)舒张压80～89 mm Hg称为高血压前期(prehypertension,PHT)[1],这一范围与我国2010年高血压防治指南中定义的"正常高值血压"的范围一致.PHT与临床高血压、心血管疾病(cardiovascular disease,CVD)、慢性肾脏病(chronic kidney disease,CKD)以及肥胖、炎症等心血管事件的其他危险因素都存在密切的关系,这一概念正越来越广泛地得到人们的认可和关注,PHT的管理主要包括生活方式调整和药物治疗.我们就高血压前期的流行趋势和管理策略做一综述.     

Coping strategies and adaptation for the disabled elderly in Taiwan

Aim: This study explored the relationship between coping strategies and adaptation difficulties for the disabled elderly. Methods: Data were collected during face‐to‐face interviews with the physically disabled elderly in long‐term care institutions and in rehabilitation departments in middle Taiwan. Totally, 505 persons were analyzed. The adaptation to disability was evaluated by health care, domestic environment, family relationships, social life and psychological distress as the dependent variables. Factor analysis and multiple regression models were applied for the analysis. Results: Three types of coping strategies were identified: (i) acceptance and action reduced the difficulty in adapting to disability in the health‐care and social life dimensions; (ii) venting and avoidance increased the difficulty in adapting in the health‐care, domestic environment and psychological distress dimensions; and (iii) seeking support was related to greater adapting to difficulty in terms of family relationships. Conclusion: More effective coping strategies should be offered to the disabled elderly to help them adapt to their disability. Geriatr Gerontol Int 2011; 11: 488–495.     

老年脑梗死的治疗进展

老年脑梗死的发病率、致残率及死亡率均较高，是严重威胁老年人群生命健康的常见病和多发病。对老年脑梗死的治疗，目前研究及临床实践所关注的是抗凝、溶栓、抗血小板、降纤治疗以及卒中单元等方面。     

Epidemiology of hyperglycemia in elderly persons

BACKGROUND: Our study used data collected in the Chung-Shing-Shin-Tseun community of Taiwan in May 1998 to evaluate the distribution of fasting glucose and the relation between hyperglycemia and the cardiovascular risk factors and sociodemographic factors in elderly persons. METHODS: Individuals aged 65 and over were recruited as study subjects. A total of 1,093 persons, out of 1,774 registered residents, were contacted in face-to-face interviews. The response rate was 61.6%. However, only 586 respondents took blood tests and completed questionnaires. Analysis in this study was based on these 586 subjects. The t test, chi-square analysis, and multivariate logistic regression were used to study the significant correlates of hyperglycemia. RESULTS: Of the individuals in our study, 66.0% were men and 34.0% were women. The mean age was 73.1 +/- 5.3 years. The mean values of fasting glucose were 5.5 +/- 1.6 mmol/L in elderly men and 5.7 +/- 2.1 mmol/L in elderly women. The hyperglycemic rates determined by modified World Health Organization criteria (> or =6.05 mmol/L) were 20.2% in elderly men and 20.7% in elderly women. Multivariate logistic regression analysis was used, after controlling the other covariates, to show that the significant related factors in hyperglycemia were obesity (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.02-4.5), high systolic pressure (OR 2.1, 95% CI 1.1-4.0), and hypertriglyceridemia (OR 2.1, 95% CI 1.03-4.4). No significant association was found between hyperglycemia and gender, age, high diastolic pressure, abnormal glutamic pyruvic transaminase, hypercholesterolemia, hyperuricemia, renal function impairment, education level, retirement status, or marital status. CONCLUSIONS: The prevalence of hyperglycemia is high in elderly persons. Hyperglycemia is significantly associated with obesity, high systolic pressure, and hypertriglyceridemia in elderly persons. It is important to examine other cardiovascular risk factors if one cardiovascular risk factor is observed.