Elderly patients can benefit from selective use of early revascularization

February 17, 2009

Data suggest age alone should not prevent more aggressive care

The elderly represent a growing proportion of patients presenting with acute myocardial infarction (MI) complicated by cardiogenic shock (CS). CS occurs when the heart fails to supply enough blood to the organs of the body, and remains the most common cause of death after heart attack among people 75 years of age and older. Proper selection of older patients for invasive management of heart disease remains a serious medical challenge, especially as the elderly are frequently underrepresented in or excluded from clinical trials.

In a study published in the February 2009 issue of JACC: Cardiovascular Interventions, researchers found the one-year survival of elderly patients (age ≥ 75 years) with acute MI complicated by CS undergoing percutaneous coronary intervention (PCI) using contemporary techniques was comparable with survival of younger patients.

"Elderly patients who are admitted to the hospital with massive heart attacks may still benefit from emergency coronary artery balloon angioplasty and stenting, despite their advanced age," says David Clark, M.B.B.S., F.R.A.C.P., senior author of the study and interventional cardiologist at Austin Hospital, Melbourne, Australia. "Although mortality occurs in roughly half of patients in these high risk situations, without this aggressive treatment, the prospect of survival is very poor."

Researchers analyzed baseline characteristics (e.g., smoking status, blood pressure, previous MI, renal function and symptom onset) and clinical outcomes, including death and emergence of other complications, in 143 consecutive patients from the Melbourne Interventional Group registry between 2004 and 2007. Elderly patients (n=45) were more likely to be female and have hypertension, previous MI, renal failure and multi-vessel coronary artery disease. Data indicated no significant differences for in-hospital, 30-day and one-year mortality in the elderly versus the younger groups.

CS is a very complicated illness to manage, often requiring timely and very specialized care. Patients typically spend significant time in intensive care, which often necessitates considerable human and financial resources. So, while outcomes data show that early revascularization can improve survival among elderly patients, other clinical factors-proper patient selection, the "physiological age" and prior condition of the patient (e.g., prior functional status, co-morbidities such as dementia and frailty) and a cost-benefit analysis of therapies-need to be considered by cardiologists.

"A patient's age in and of itself should not be used to deny someone more aggressive, invasive care with angioplasty for cardiogenic shock," says Judith S. Hochman, M.D., F.A.C.C., F.A.H.A., Harold Snyder Family Professor of Cardiology and director of the Cardiovascular Clinical Research Center, New York University School of Medicine.

"Having said that, we need to better understand and standardize criteria to improve selection of older patients who are likely to benefit. For example, as shown in this study, better kidney function clearly is a useful indicator that a patient will do well. What we don't want is to subject patients to uncomfortable, unnecessary procedures if they will not derive a benefit in terms of quality of life or life prolongation."

The elderly in particular are at increased risk for other complications. Authors add that further investigation of the selective use of early revascularization among this patient population is needed.

American College of Cardiology

---

---

	Cardiogenic Shock (American Heart Association Clinical Series) by Judith S. Hochman (Editor), E. Magnus Ohman MD (Editor) * A comprehensive source of information on the management of cardiogenic shock * Part of the AHA Clinical Series published in conjunction with the American Heart Association * Focuses on high-interest and emerging topics in cardiovascular disease targeted to cardiologists and other interested healthcare providers * A useful tool for investigating, evaluating and treating one of the most important lingering challenges in acute cardiovascular care
	Cardiogenic Shock by Steve Hollenberg (Editor), Eric Bates (Editor) This timely and comprehensive review is the only book to focus on the importance of treating cardiogenic shock as a discrete condition, not merely a symptom of another disease. The editors and authors are esteemed clinicians and investigators who have furthered our knowledge of the evaluation and management of cardiogenic shock. Contributors to this book comprise an international group of multidisciplinary specialists with extensive expertise in various aspects of cardiogenic shock, who have balanced their knowledge of pathophysiology and cutting-edge therapeutic approaches with their experience and unique perspectives.Practical management strategies based on the latest data from randomised trials of treatment strategies - including SHOCK, SMASH, and TACTICS - are discussed. Detailed...
	Cardiogenic Shock (Contemporary Cardiology) by David Hasdai (Editor), Peter B. Berger (Editor), Alexander Battler (Editor), David R. Holmes Jr. (Editor) Leading world authorities drawn from cardiology, surgery, pediatrics, internal medicine, and basic science comprehensively survey the diagnostic, therapeutic, and prognostic aspects of cardiogenic shock. These experts describe the different scenarios leading to cardiogenic shock, the ways to diagnose their causes, the unique therapeutic options based on those causes, and the outcomes associated with treatment and without. The book also surveys the biochemical and physiological changes that occur in the heart and other organs during cardiogenic shock, the identification of patients at risk for developing shock, and the novel pharmacological agents and assist devices that can help to stabilize the shock patient.
	Cardiogenic shock; mechanism and management by Richard J Kones (Author)
	Myocardial Infarction: Cardiogenic Shock Unit 4 (Continuing education in cardiovascular nursing) by Anna L. Seal (Author)
	Shock in Myocardial Infarction (Clinical cardiology monographs) by R.M. Gunnar (Author), etc. (Author)
	Complete Medical Guide and Prevention for Heart Disease Volume VIII; Cardiogenic Shock by New Creative Heart is a muscular organ that located the center of the circulatory system. It pumps blood throughout body via blood vessels network, such as capillaries, arteries and veins. Blood is delivered to and from all parts of body by these blood vessels. At the optimal rate required to function well, a healthy heart provides your entire body with the proper quantity of blood. If disease or injury impairs your heart, your body's organs won't obtain enough blood to operate regularly. Cardiopathy, commonly known as cardiac disease or heart disease, is an hyponym for a various diseases affecting the heart. Since 2007, it is one of the major cause of death in the United States, Canada and some European countries such as England and Wales, representing about 25.4% of the total...
	Revascularization Benefits Cardiogenic Shock.: An article from: Family Practice News by Bruce Jancin (Author), Mitchel L. Zoler (Author) This digital document is an article from Family Practice News, published by International Medical News Group on May 15, 1999. The length of the article is 1410 words. The page length shown above is based on a typical 300-word page. The article is delivered in HTML format and is available in your Amazon.com Digital Locker immediately after purchase. You can view it with any web browser. Citation Details Title: Revascularization Benefits Cardiogenic Shock. Author: Bruce Jancin Publication: Family Practice News (Magazine/Journal) Date: May 15, 1999 Publisher: International Medical News Group Volume: 29 Issue: 10 Page: 34 Distributed by Thomson...
	Cardiogenic shock in hypothyroidism.(Case Report): An article from: Southern Medical Journal by Mahi Lakshmi Ashwath (Author), Gurjaipal Kang (Author), Mike Cunningham (Author), Dale S. Adler (Author) This digital document is an article from Southern Medical Journal, published by Thomson Gale on May 1, 2006. The length of the article is 1525 words. The page length shown above is based on a typical 300-word page. The article is delivered in HTML format and is available in your Amazon.com Digital Locker immediately after purchase. You can view it with any web browser. Citation Details Title: Cardiogenic shock in hypothyroidism.(Case Report) Author: Mahi Lakshmi Ashwath Publication: Southern Medical Journal (Magazine/Journal) Date: May 1, 2006 Publisher: Thomson Gale Volume: 99 Issue: 5 Page: 515(3) Distributed by Thomson...
	Ventricular septal rupture and cardiogenic shock in the myocardial infarction case presenting with fever and leukocytosis / Ates ve lokositoz ile ... of Cardiology (Anadolu Kardiyoloji Dergisi) by Ozgur Tanriverdi (Author) This digital document is an article from The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi), published by Thomson Gale on December 1, 2007. The length of the article is 770 words. The page length shown above is based on a typical 300-word page. The article is delivered in HTML format and is available in your Amazon.com Digital Locker immediately after purchase. You can view it with any web browser. Citation Details Title: Ventricular septal rupture and cardiogenic shock in the myocardial infarction case presenting with fever and leukocytosis / Ates ve lokositoz ile prezente olan akut miyokard enfarktusu olgusunda ventrikul septum rupturu ve kardiyojenik sok.(Letters to the Editor / Editore Mektuplar) Author: Ozgur Tanriverdi Publication: The Anatolian...