Post-Acute MI Survival Improving for Elderly Patients in France

BARCELONA, Spain—Elderly patients are living longer after acute myocardial infarction (MI) than they were 20 years ago as a result of better management, according to a study presented on August 30, 2014, at the European Society of Cardiology Congress.

“This improvement can be explained in our data by increasing use of early PCI, newer anticoagulants—especially [low molecular weight heparin]—and recommended medications,” said Etienne Puymirat, MD, of Hôpital Européen Georges-Pompidou (Paris, France). 

In that oldest age group, the average age remained consistent over time at about 82 years. Across surveys, the prevalence of hypertension, hypercholesterolemia, and diabetes increased and patients became more likely to have a history of previous PCI or CABG and less likely to have a history of heart failure. In later surveys, patients also were less likely to present with STEMI—a result of the changing definition of ACS, according to Dr. Puymirat—and more likely to present with Killip class I symptoms. 

Management Gets Better Over Time

The initial management of patients improved across surveys. Use of the following medications in the first 48 hours of hospitalization increased: antiplatelets, thienopyridines, glycoprotein IIb/IIIa inhibitors, statins, beta-blockers, ACE inhibitors, and angiotensin receptor blockers. In addition, low molecular weight heparin (LMWH) appeared to displace the use of unfractionated heparin. 

Among the NSTEMI population, gains were seen over time in the percentage of patients who had a coronary angiogram during hospitalization and who underwent PCI within the first 72 hours.

Among STEMI patients, the percentage who did not undergo reperfusion or were reperfused with lysis declined, while the rate of primary PCI climbed (from 5% in 1995 to 58% in 2010). Median symptom onset-to-admission time dropped, whereas the onset-to-reperfusion time remained relatively stable.                                                                                                                            

Survival Improves with Better Management

Mortality in the first month after MI declined across surveys from 28% to 11% in STEMI patients and from 18% to 6% in NSTEMI patients. Similarly, 1-year mortality overall fell from 36% to 20%, with similar reductions seen in both STEMI and NSTEMI patients. 

After adjustment for clinical presentation only, the risk of 1-year mortality was lower during each time period compared with 1995, with greater reductions over time (table 1).

Table 1. Risk of 1-Year Mortality Between Time Periods (vs 1995)

After taking into account initial management with drugs and procedures, however, there were no longer differences in mortality between the time periods.

PCI alone and the use of LMWH—either alone or in combination with PCI—were associated with lower 1-year mortality compared with the lack of both PCI within 72 hours and no LMWH (table 2). 

Table 2. Risk of 1-Year Mortality Based on Use of PCI and LMWH

Mortality through the first year was also lower with early use of beta-blockers (HR 0.48; 95% CI 0.41-0.56), ACE inhibitors (HR 0.81; 95% CI 0.70-0.94), and statins (HR 0.83; 95% CI 0.69-1.00).

Responding to an observation from one of the co-chairs of the session at which he presented the results, Dr. Puymirat noted that the separation of the survival curves in the first month after MI—with little additional widening beyond that—highlights the importance of early PCI and use of recommended medications on mortality early on, with less impact further out.

Source:
Puymirat E, Schiele F, Elbaz M, et al. Major improvement in 1-year mortality in elderly patients admitted with AMI in relation with early PCI and recommended medications: data from the FAST-MI program 1995-2010. Presented at: European Society of Cardiology Congress; August 30, 2014; Barcelona, Spain.
 

 Related Stories:

• FAST-MI Registry: Fibrinolysis, Primary PCI Yield Similar 5-Year Survival in STEMI Patients
• Early Invasive Strategy in NSTEMI Patients Improves Survival
• Improvements in Revascularization Reduce Cardiac Death, MI, and Repeat Revascularization, but not All-Cause Mortality in Japan