Temporal trends, characteristics and outcomes of fibrinolytic therapy for ST-elevation myocardial infarction among patients 80 years or older
Corresponding Author
Gbolahan O. Ogunbayo MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Correspondence
Gbolahan O. Ogunbayo, Division of Cardiovascular Medicine, University of Kentucky, 326 C.T. Wethington Bldg., 900 South Limestone Street, Lexington, KY 40536-0200.
[email protected] or [email protected]
Search for more papers by this authorNaoki Misumida MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorKaram Ayoub MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorYared Hailemariam MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorDustin Hillerson MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorAyman Elbadawi MD, MS
Department of Internal Medicine, Rochester General Hospital, Rochester, New York
Search for more papers by this authorAhmed Abdel-Latif MD, PhD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorSusan Smyth MD, PhD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorKhaled Ziada MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorAdrian W. Messerli MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorCorresponding Author
Gbolahan O. Ogunbayo MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Correspondence
Gbolahan O. Ogunbayo, Division of Cardiovascular Medicine, University of Kentucky, 326 C.T. Wethington Bldg., 900 South Limestone Street, Lexington, KY 40536-0200.
[email protected] or [email protected]
Search for more papers by this authorNaoki Misumida MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorKaram Ayoub MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorYared Hailemariam MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorDustin Hillerson MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorAyman Elbadawi MD, MS
Department of Internal Medicine, Rochester General Hospital, Rochester, New York
Search for more papers by this authorAhmed Abdel-Latif MD, PhD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorSusan Smyth MD, PhD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorKhaled Ziada MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorAdrian W. Messerli MD
Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
Search for more papers by this authorAbstract
Background
Pharmacologic reperfusion therapy is a recommended and effective strategy in patients with ST-elevation myocardial infarction (STEMI) when percutaneous coronary intervention (PCI) is not available. This study investigates temporal trends and outcomes of fibrinolytic therapy (FT) in elderly patients with STEMI.
Methods
Using the Nationwide Inpatient Sample database, we extracted patients ≥80 years a primary diagnosis of STEMI admitted between 2010 and 2014. Using ICD codes, we identified patients who underwent FT. We performed temporal trend analysis, then compared characteristics and inpatient outcomes in the FT group versus no-FT group. Our primary outcome of interest was hemorrhagic stroke (HS). We also assessed the impact of HS on mortality and discharge to skilled nursing facility (SNF).
Results
Of the 917,307 patients with STEMI, 16.1% (n = 147,874) were aged 80 or older. Primary PCI was performed in 46.2%, 2.4% underwent FT, and 51.3% had neither pharmacologic nor mechanical revascularization. The rate of FT increased (1.9%–2.4%) in a nonlinear trend over the five years of the study. The FT group was eight times more likely to suffer HS (P < 0.001). FT was an independent predictor of HS (OR 7.90, 95% CI 4.36–14.30; P < 0.001), whether they underwent PCI or not. HS was an independent predictor of mortality and SNF discharge.
Conclusion
FT in patients 80 years or older presenting with STEMI was associated with an eight-fold increase in HS and no associated mortality advantage, both with or without PCI. These data underscore the increased risk of FT in the elderly.
CONFLICT OF INTEREST
Nothing to report.
Supporting Information
| Filename | Description |
|---|---|
| ccd27833-sup-0001-TableS1.docxWord 2007 document , 14.4 KB | Supplemental Table 1: ICD coded of variables used |
| ccd27833-sup-0002-Tables.docxWord 2007 document , 33.1 KB |
Supplemental Table 2: Baseline characteristics of Patients ≥80 years that underwent fibrinolytic therapy and PCI and those underwent PCI only. Supplemental Table 3: In-hospital outcomes of patients ≥80 years that underwent fibrinolytic therapy and PCI and those underwent PCI only. Supplemental Table 4: Baseline characteristics of Patients ≥80 years that underwent fibrinolytic therapy without PCI and those underwent neither PCI nor Fibrinolytic therapy. Supplemental Table 5: In-hospital outcomes of patients ≥80 years that underwent fibrinolytic therapy without PCI and those underwent neither PCI nor Fibrinolytic therapy. |
| ccd27833-sup-0003-FigureS1.tiffTIFF image, 239.1 KB | Supplemental Figure 1: Study design |
| ccd27833-sup-0004-FigureS2.tiffTIFF image, 430.1 KB | Supplemental Figure 2: Incidence of hemorrhagic stroke in patients 80 years or older admitted for ST-elevation myocardial infarction. |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
REFERENCES
- 1O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: Executive summary: A report of the American college of cardiology foundation/American heart association task force on practice guidelines. J Am Coll Cardiol 2013; 61(4): E425–E432. doi:https://doi.org/10.1016/j.jacc.2012.11.018.
- 2Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2018; 39(2): 119–177. doi:https://doi.org/10.1093/eurheartj/ehx393.
- 3Armstrong PW, Gershlick AH, Goldstein P, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013; 368(15): 1379–1387. doi:https://doi.org/10.1056/NEJMoa1301092.
- 4 Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): Randomised trial. Lancet 2006; 367(9510): 569–578. doi:10.1016/S0140-6736(06)68147-6.
- 5Soumerai SB, McLaughlin TJ, Ross-Degnan D, Christiansen CL, Gurwitz JH. Effectiveness of thrombolytic therapy for acute myocardial infarction in the elderly: Cause for concern in the old-old. Arch Intern Med 2002; 162(5): 561–568.
- 6Thiemann DR, Coresh J, Schulman SP, Gerstenblith G, Oetgen WJ, Powe NR. Lack of benefit for intravenous thrombolysis in patients with myocardial infarction who are older than 75 years [see comments]. Circulation 2000; 101(19): 2239–2246.
- 7Angeja BG, Rundle AC, Gurwitz JH, Gore JM, Barron HV. Death or nonfatal stroke in patients with acute myocardial infarction treated with tissue plasminogen activator. Am J Cardiol 2001; 87(5): 627–630.
- 8Mehta RH, Granger CB, Alexander KP, Bossone E, White HD, Sketch MH. Reperfusion strategies for acute myocardial infarction in the elderly: Benefits and risks. J Am Coll Cardiol 2005; 45(4): 471–478. doi:https://doi.org/10.1016/j.jacc.2004.10.065.
- 9Steiner C, Elixhauser A, Schnaier J. The healthcare cost and utilization project: An overview. Eff Clin Pract 2002; 5(3): 143–151.
- 10 Agency for Healthcare Research and Quality, Rockville M. HCUP Databases. Healthcare Cost and Utilization Project (HCUP). Available at: http://www.hcup-us.ahrq.gov/nisoverview.jsp. Published 2016. Accessed on November 22, 2016.
- 11Deshmukh A, Patel NJ, Pant S, et al. In-hospital complications associated with catheter ablation of atrial fibrillation in the United States between 2000 and 2010: Analysis of 93 801 procedures. Circulation 2013; 128(19): 2104–2112. doi:https://doi.org/10.1161/CIRCULATIONAHA.113.003862.
- 12Ogunbayo GO, Charnigo R, Darrat Y, et al. Incidence, predictors, and outcomes associated with pneumothorax during cardiac electronic device implantation: A 16-year review in over 3.7 million patients. Heart Rhythm 2017; 14(12): 1764–1770. doi:https://doi.org/10.1016/j.hrthm.2017.07.024.
- 13 Agency for Healthcare Research and Quality, Rockville M. HCUP NIS trend weights. Healthcare cost and utilization project (HCUP). Available at: www.hcup-us.ahrq.gov/db/nation/nis/trendwghts.jsp. Published 2015. Accessed on November 23, 2016.
- 14 Agency for Healthcare Research and Quality, Rockville M. HCUP CCS. Healthcare cost and utilization project (HCUP). Available at: https://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp. Published 2016. Accessed on November 22, 2016.
- 15Alshekhlee A, Horn C, Jung R, Alawi AA, Cruz-Flores S. In-hospital mortality in acute ischemic stroke treated with hemicraniectomy in US Hospitals. J Stroke Cerebrovasc Dis 2011; 20(3): 196–201. doi:https://doi.org/10.1016/j.jstrokecerebrovasdis.2009.11.019.
- 16Ogunbayo GO, Misumida N, Olorunfemi O, et al. Comparison of outcomes in patients having acute myocardial infarction with versus without sickle-cell anemia. Am J Cardiol 2017; 120: 1768–1771. doi:https://doi.org/10.1016/j.amjcard.2017.07.108.
- 17 Agency for Healthcare Research and Quality, Rockville M. HCUP NIS description of data elements. Healthcare cost and utilization project (HCUP). Available at: www.hcup-us.ahrq.gov/db/vars/hosp_location/nisnote.jsp. Published 2008. Accessed on November 22, 2016.
- 18 Census Bereau US. Geographic Terms and Concepts—Core Based Statistical Areas and Related Statistical Areas. Available at: https://www.census.gov/geo/reference/gtc/gtc_cbsa.html. Published 2012. Accessed on November 22, 2016.
- 19Nationwide Inpatient Sample (NIS). Description of Data Elements. AHAID—AHA hospital identifier. DISCWT Weight to discharges in the universe. 1988;7:1–25.
- 20Sepúlveda C, Palomo I, Fuentes E. Mechanisms of endothelial dysfunction during aging: Predisposition to thrombosis. Mech Ageing Dev 2017;164: 91–99. doi:https://doi.org/10.1016/j.mad.2017.04.011.
- 21Sepúlveda C, Palomo I, Fuentes E. Primary and secondary haemostasis changes related to aging. Mech Ageing Dev 2015; 150: 46–54. doi:https://doi.org/10.1016/j.mad.2015.08.006.
- 22Fuentes E, Palomo I. Role of oxidative stress on platelet hyperreactivity during aging. Life Sci 2016; 148: 17–23. doi:https://doi.org/10.1016/j.lfs.2016.02.026.
- 23Abou-Ismail MY, Ogunbayo GO, Secic M, Kouides PA. Outgrowing the laboratory diagnosis of Type 1 Von Willebrand Disease: A two decade study. Am J Hematol 2018; 93(2): 232–237. doi:https://doi.org/10.1002/ajh.24962.
- 24Uryga AK, Bennett MR. Ageing induced vascular smooth muscle cell senescence in atherosclerosis. J Physiol 2016; 594(8): 2115–2124. doi:https://doi.org/10.1113/JP270923.
- 25Wang JC, Bennett M. Aging and atherosclerosis: Mechanisms, functional consequences, and potential therapeutics for cellular senescence. Circ Res 2012; 111(2): 245–259. doi:https://doi.org/10.1161/CIRCRESAHA.111.261388.
- 26Leiss W, Méan M, Limacher A, et al. Polypharmacy is associated with an increased risk of bleeding in elderly patients with venous thromboembolism. J Gen Intern Med 2015; 30(1): 17–24. doi:https://doi.org/10.1007/s11606-014-2993-8.
- 27Kruse-Jarres R. Acquired bleeding disorders in the elderly. Hematology Am Soc Hematol Educ Program 2015; 2015: 231–236. doi:https://doi.org/10.1182/asheducation-2015.1.231.
- 28Sinnaeve PR, Huang Y, Bogaerts K, et al. Age, outcomes, and treatment effects of fibrinolytic and antithrombotic combinations: Findings from Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT)-3 and ASSENT-3 PLUS. Am Heart J 2006; 152(4): 684.e1-9. doi:https://doi.org/10.1016/j.ahj.2006.07.005.
- 29Collins R, Peto R, Baigen C, Sleight P. Aspirin, heparin, and fibrinolytic therapy in suspected acute myocardial. N Engl J Med 1997; 847–860.
- 30Danchin N, Coste P, Ferrières J, et al. Comparison of thrombolysis followed by broad use of percutaneous coronary intervention with primary percutaneous coronary intervention for ST-segment-elevation acute myocardial infarction: Data from the French registry on acute ST-elevation myocardial inf. Circulation 2008; 118(3): 268–276. doi:https://doi.org/10.1161/CIRCULATIONAHA.107.762765.
- 31Danchin N, Puymirat E, Steg PG, et al. Five-Year survival in patients with ST-Segment-elevation myocardial infarction according to modalities of reperfusion therapy: The French registry on acute ST-elevation and non-ST-Elevation myocardial infarction (FAST-MI) 2005 cohort. Circulation 2014; 129(16): 1629–1636. doi:https://doi.org/10.1161/CIRCULATIONAHA.113.005874.
- 32Meit M, Knudson A, Gilbert T, et al. The 2014 Update of the Rural-Urban Chartbook. Rural Health Reform Policy Res Cent. 2014; 1–153.
- 33Claeys MJ, Sinnaeve PR, Convens C, et al. STEMI mortality in community hospitals versus PCI-capable hospitals: Results from a nationwide STEMI network programme. Eur Heart J Acute Cardiovasc Care 2012; 1(1): 40–47. doi:https://doi.org/10.1177/2048872612441579.
- 34Knudson A, Meit M, Popat S. Rural-urban disparities in heart disease. Policy Brief, Rural Health Reform Policy Res Cent 2014; 1–6.
- 35O'Connor A, Wellenius G. Rural-urban disparities in the prevalence of diabetes and coronary heart disease. Public Health. 2012; 126(10): 813–820. doi:https://doi.org/10.1016/j.puhe.2012.05.029.
- 36Wang TY, Gutierrez A, Peterson ED. Percutaneous coronary intervention in the elderly. Nat Rev Cardiol 2010; 8(2): 79–90. doi:https://doi.org/10.1038/nrcardio.2010.184.
- 37Bueno H, Betriu A, Heras M, et al. Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio en Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J 2011; 32(1): 51–60. doi:https://doi.org/10.1093/eurheartj/ehq375.
- 38Van Lammeren GW, Reichmann BL, Moll FL, et al. Atherosclerotic plaque vulnerability as an explanation for the increased risk of stroke in elderly undergoing carotid artery stenting. Stroke 2011; 42(9): 2550–2555. doi:https://doi.org/10.1161/STROKEAHA.110.607382.
- 39Liu F, Guo Q, Xie G, Zhang H, Wu Y, Yang L. Percutaneous coronary intervention after fibrinolysis for ST-segment elevation myocardial infarction patients: An updated systematic review and meta-analysis. PLoS One 2015; 10(11): 1–16. doi:https://doi.org/10.1371/journal.pone.0141855.
- 40Thiele H, Eitel I, Meinberg C, et al. Randomized comparison of pre-hospitalinitiated facilitated percutaneous coronary intervention versus primary percutaneous coronary intervention in acute myocardial infarction very early after symptom onset: The LIPSIA-STEMI trial (Leipzig Immediate Prehos). JACC Cardiovasc Interv 2011; 4(6): 605–614. doi:https://doi.org/10.1016/j.jcin.2011.01.013.
- 41Widimský P, Budesinsky T, Voráč D, et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction: Final results of the randomized national multicentre trial-PRAGUE-2. Eur Heart J 2003; 24(1): 94–104. doi:https://doi.org/10.1016/S0195-668X(02)00468-2.
- 42Mongkhon P, Dilokthornsakul P, Tepwang K, et al. The effects of fibrinolytic before referring STEMI patients: A systematic review and meta-analysis. Int J Cardiol Heart Vasc 2017; 15: 9–14. doi:https://doi.org/10.1016/j.ijcha.2017.03.003.
- 43Kawecki D, Gierlotka M, Morawiec B, et al. Direct admission versus interhospital transfer for primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. JACC Cardiovasc Interv 2017; 10(5): 438–447. doi:https://doi.org/10.1016/j.jcin.2016.11.028.
- 44Kanakakis J, Nanas JN, Tsagalou EP, et al. Multicenter randomized trial of facilitated percutaneous coronary intervention with low-dose tenecteplase in patients with acute myocardial infarction: The ATHENS PCI trial. Catheter Cardiovasc Interv 2009; 74(3): 398–405. doi:https://doi.org/10.1002/ccd.22009.
- 45Armstrong PW. FASTTRACK: A comparison of pharmacologic therapy with/without timely coronary intervention vs. primary percutaneous intervention early after ST-elevation myocardial infarction: The WEST (Which Early ST-elevation myocardial infarction Therapy) study. Eur Heart J 2006; 27(13): 1530–1538. doi:https://doi.org/10.1093/eurheartj/ehl088.
- 46Claeys MJ, de Meester A, Convens C, et al. Contemporary mortality differences between primary percutaneous coronary intervention and thrombolysis in ST-segment elevation myocardial infarction. Arch Intern Med 2011; 171(6): 544–549. doi:https://doi.org/10.1001/archinternmed.2011.57.
- 47Vandecasteele EH, De Buyzere M, Gevaert S, et al. Reperfusion therapy and mortality in octogenarian STEMI patients: Results from the Belgian STEMI registry. Clin Res Cardiol 2013; 102(11): 837–845. doi:https://doi.org/10.1007/s00392-013-0600-3.
- 48Saposnik G, Black S. Stroke in the very elderly: Hospital care, case fatality and disposition. Cerebrovasc Dis 2009; 27(6): 537–543. https://www.karger.com/DOI/10.1159/000214216.
- 49Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics’2017 update: A report from the American Heart Association. Circulation 2018; 137(12): e67-e492. doi:https://doi.org/10.1161/CIR.0000000000000485.
