Very Elderly STEMI Patients Do Better With PCI, but ‘Eyeballing’ Is Insufficient for Decision Making
Patients in their mid-to-late 80s and older are less likely to die after a STEMI when treated with PCI rather than a conservative treatment approach, according to a small study. But critical selection criteria, such as functional status and frailty, are subjective and could lead to the exclusion of patients who may in fact have better outcomes with intervention.
“It is evident decision making in patients aged [at least] 85 years requires consideration of age, comorbidities, functional and cognitive status, frailty, as well as patient’s wishes,” write Matias B. Yudi, MBBS (University of Melbourne, Australia), and colleagues. “At present there are no validated tools incorporating all these variables that can be used quickly when assessing a STEMI patient.”
In the study, published online April 21, 2016, before print in the American Journal of Cardiology, Yudi and colleagues looked at outcomes of 101 consecutive STEMI patients aged 85 years and older who were treated at a tertiary Australian hospital between November 2011 and July 2015. Just over half (55%) were managed conservatively, with the remainder (45%) receiving invasive management.
Overall, short- and long-term mortality were much higher in those treated with a conservative approach.
Compared with the conservatively managed group, older patients who received revascularization were younger, had less cognitive impairment, had lower Charlson age-comorbidity index score, and were more likely to be independent in activities of daily living and mobility. On multivariate analysis, older age, anterior STEMI, and cognitive impairment were independent predictors of conservative treatment.
Invasive management was the only independent predictor of lower long-term mortality (HR 0.29; 95% CI 0.11-0.76).
Other 12-month outcomes, including recurrent MI, cerebrovascular accident, cardiac rhythm disturbances, and in-hospital or major bleeding, were similar regardless of management strategy.
End-of-the-Bed Assessments Flawed
As the researchers note, selection of invasive management for older STEMI patients is made at the discretion of their physicians. This, they say, is due to lack of data on outcomes in the population. Early STEMI trials recruited fewer than 2% of patients older than age 85.
“Although the highly selected patients in [our] invasive arm had favorable outcomes, it is still unclear whether a greater proportion of patients aged ≥ 85 years, particularly those with higher-risk features, should undergo invasive management,” Yudi and colleagues write.
While clinical judgement about functional status “appears accurate” for patients with severe impairment, it is inadequate for assessing those with more moderate impairment, particularly in the setting of an emergency department, the researchers observe.
They cite one study that found over half of patients identified as being dependent in key activities of daily living were actually independent. “This could adversely affect a patient’s treatment given those who are independent with mobility and activities of daily living are more likely to be managed invasively,” according to Yudi and colleagues.
Frailty assessments, too, often fall victim to the “eyeball test” in the very elderly and may result in clinicians labeling patients as too frail for intervention based solely on an “end-of-the-bed assessment,” they say.
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Yudi MB, Jones N, Fernando D, et al. Management of patients ≥ 85 years of age with ST-elevation myocardial infarction. Am J Cardiol. 2016;Epub ahead of print.
- Yudi reports no relevant conflicts of interest.