Anti-thrombotic strategies in elderly patients receiving platelet inhibitors

Abstract Acetyl-salicylic acid is the basic anti-thrombotic therapy used for single anti-platelet therapy in primary as well as secondary prevention of atherosclerotic disease. Dual anti-platelet therapy (DAPT) is the cornerstone of maintenance medication following elective percutaneous coronary intervention or acute coronary syndromes (ST elevation myocardial infarction, non-ST elevation myocardial infarction, unstable angina). DAPT duration has been frequently discussed. Currently, guideline recommendations strengthen the importance of individualized treatment to reduce bleeding risk based on clinical predictors, of which older age is an important one. Patients aged ≥75 years are often underrepresented in randomized clinical trials, but present a patient cohort deemed both at heightened ischaemic as well as bleeding risk. We aimed to summarize the evidence or the lack of evidence for anti-platelet treatment strategies in patients aged ≥75 years including combinations with anticoagulants in secondary prevention or coronary interventions in elderly patients with atrial fibrillation. This review article represents the author’s interpretation of available data and is not discussed by a formal task force; it is intended to point out missing evidence and to provide age-specific data for individualized decision making, which is currently encouraged by the guidelines.

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The current treatment and predictors of outcome in elderly patients with non-ST-elevation myocardial infarction in an all comers population: the POPular Age registry

European Heart Journal ◽

10.1093/ehjci/ehaa946.3248 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M.E Gimbel ◽

D.R.P.P Chan Pin Yin ◽

R.S Hermanides ◽

F Kauer ◽

A.H Tavenier ◽

...

Keyword(s):

Myocardial Infarction ◽

Elderly Patients ◽

Major Bleeding ◽

Oral Anticoagulation ◽

Dual Antiplatelet Therapy ◽

Bleeding Risk ◽

Cardiovascular Death ◽

St Elevation ◽

One Year

Abstract Background Elderly patients form a large and growing part of the patients presenting with non-ST-elevation myocardial infarction (NSTEMI). Choosing the optimal antithrombotic treatment in these elderly patients is more complicated because they frequently have characteristics indicating both a high ischaemic and high bleeding risk. Purpose We describe the treatment of elderly patients (>75 years) admitted with NSTEMI, present the outcomes (major adverse cardiovascular events (MACE) and bleeding) and aim to find predictors for adverse events. Methods The POPular AGE registry is an investigator initiated, prospective, observational, multicentre study of patients aged 75 years or older presenting with NSTEMI. Patients were recruited between August 1st, 2016 and May 7th, 2018 at 21 sites in the Netherlands. The primary composite endpoint of MACE included cardiovascular death, non-fatal myocardial infarction and non-fatal stroke at one-year follow-up. Results A total of 757 patients were enrolled. During hospital stay 76% underwent coronary angiography, 34% percutaneous coronary intervention and 12% coronary artery bypass grafting (CABG). At discharge 78.6% received aspirin (non-users mostly because of the combination of oral anticoagulant and clopidogrel), 49.7% were treated with clopidogrel, 34.2% with ticagrelor and 29.6% were prescribed oral anticoagulation. Eighty-three percent of patients received dual antiplatelet therapy (DAPT) or dual therapy consisting of oral anticoagulation and at least one antiplatelet agent for a duration of 12 months. At one year, the primary outcome of cardiovascular death, myocardial infarction or stroke occurred in 12.3% of patients and major bleeding (BARC 3 or 5) occurred in 4.8% of the patients. The risk of MACE and major bleeding was highest during the first month and stayed high over time for MACE while the risk for major bleeding levelled off. Independent predictors for MACE were age, renal function, medical history of CABG, stroke and diabetes. The only independent predictor for major bleeding was haemoglobin level on admission. Conclusion In this all-comers registry, most elderly patients (≥75 years) with NSTEMI are treated with DAPT and undergoing coronary angiography the same way as younger NSTEMI patients from the SWEDEHEART registry. Aspirin use was lower as was the use of the more potent P2Y12 inhibitors compared to the SWEDEHEART which is very likely due to the concomitant use of oral anticoagulation in 30% of patients. The fact that ischemic risk stays constant over 1 year of follow-up, while the bleeding risk levels off after one month may suggest the need of dual antiplatelet therapy until at least one year after NSTEMI. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca

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Early and late clinical outcome in elderly patients after revascularization with Primary Percutaneous Coronary Intervention presenting with acute ST-elevation myocardial infarction: Results from Qassim Primary Angioplasty Services (QAPAS) registry

Journal of the Saudi Heart Association ◽

10.1016/j.jsha.2012.06.241 ◽

2012 ◽

Vol 24 (4) ◽

pp. 290

Author(s):

Mehboob Ali Dar ◽

Akif Ali Mufti ◽

Adil Azmy ◽

Yasir Beshir ◽

Hassan Khalaf ◽

...

Keyword(s):

Myocardial Infarction ◽

Percutaneous Coronary Intervention ◽

Clinical Outcome ◽

Elderly Patients ◽

Primary Percutaneous Coronary Intervention ◽

Coronary Intervention ◽

Primary Angioplasty ◽

St Elevation Myocardial Infarction ◽

Percutaneous Coronary ◽

St Elevation

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Elderly Asian Patients Have Lower Revascularisation Rates and Poorer Outcomes for ST-Elevation Myocardial Infarction Compared to Younger Patients

Annals of the Academy of Medicine, Singapore ◽

10.47102/annals-acadmedsg.19110 ◽

2020 ◽

Vol 49 (1) ◽

pp. 3-14

Author(s):

James X Cai ◽

Jonathan Yap ◽

Fei Gao ◽

Tian Hai Koh ◽

Khim Leng Tong ◽

...

Keyword(s):

Myocardial Infarction ◽

Percutaneous Coronary Intervention ◽

Elderly Patients ◽

Young Patients ◽

Coronary Intervention ◽

St Elevation Myocardial Infarction ◽

Younger Patients ◽

Asian Patients ◽

Percutaneous Coronary ◽

St Elevation

Introduction: There is limited information on elderly patients presenting with ST elevation myocardial infarction (STEMI). This study aimed to study the outcomes of elderly Asian patients with STEMI compared to younger patients. Materials and Methods: The study utilised data from 2007 to 2012 from the Singapore Myocardial Infarction Registry, a mandatory national population-based registry. Elderly patients were defined as ≥80 years of age, middle-aged to old (MAO) patients were defined as 45–80 years of age and young patients were defined as ≤45 years of age. The primary outcome of the study was 1-year mortality and secondary outcomes included in-hospital complications and mortality. Results: There were 12,409 STEMI patients with 1207 (9.7%) elderly patients, 10,093 (81.3%) MAO patients and 1109 (8.9%) young patients. Elderly patients had more cardiovascular risk factors and lower rates of total percutaneous coronary intervention (26.0% vs 72.4% vs 85.5%, respectively; P <0.0001) compared to MAO and young patients. They had higher 1-year mortality (60.6% vs 18.3% vs 4.1%, respectively; P <0.0001) when compared to MAO and young patients. Conclusion: Elderly patients with STEMI have poorer outcomes than MAO and young patients. This is potentially attributable to a myriad of factors including age, higher burden of comorbidities and a lesser likelihood of receiving revascularisation and guideline-recommended medical therapy. Keywords: Coronary artery bypass graft, Percutaneous coronary intervention

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THROMBOLYTIC EFFICACY OF STREPTOKINASE IN ELDERLY TYPE 2 DIABETES MELLITUS WITH ACUTE ST ELEVATION MYOCARDIAL INFARCTION USING ELECTROCARDIOGRAPHIC ST-SEGMENT RESOLUTION

10.36106/ijsr/2102452 ◽

2021 ◽

pp. 67-70

Author(s):

Mahendra Pratap ◽

Somil Verma ◽

S. L. Mathur

Keyword(s):

Myocardial Infarction ◽

Elderly Patients ◽

Thrombolytic Therapy ◽

Care Center ◽

Tertiary Care ◽

St Elevation Myocardial Infarction ◽

Diabetic Patients ◽

Common Location ◽

St Segment ◽

St Elevation

Background: Age and diabetes are important prognostic factors in patients with acute ST-elevation myocardial infarction (STEMI) undergoing thrombolysis. In our study we compared the post-thrombolytic effect of streptokinase in elderly diabetic and non-diabetic patients. Methods: A prospective observational study was conducted in tertiary care center of India in which 140 elderly patients diagnosed with STEMI and undergoing thrombolytic therapy with streptokinase were enrolled after making necessary exclusions and were divided into diabetic (n=70) and non-diabetic (n=70) as study and control groups respectively. ECG was done immediately before and at 60 minutes after thrombolytic therapy. ST-segment resolution was measured and patients were classied as failed (<30%), partial (30-70%) and successful (>70%) resolution of STsegment. Results: Failed thrombolysis was evident in 34.3% non-diabetic and 57.1% diabetic patients (p=0.010). The incidence of successful thrombolysis was present in 41.4% non-diabetic and 28.6% diabetic patients, whereas partial thrombolysis was seen in 24.3% non-diabetic and 14.3% diabetics. Anterior wall was the most common location of infarction in elderly population but the proportion was higher in diabetics than non-diabetics (p=0.025). Conclusion: Failed thrombolysis with streptokinase was higher in diabetics than in non-diabetics after 60 minutes of streptokinase infusion in elderly patients warranting the need of using another cost effective and easily available agent for elderly diabetic population.

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Abstract 14977: St-elevation Myocardial Infarction in Multi Vessel Coronary Artery Disease- What to Do? Network Meta-analysis of Revascularization Strategies

Circulation ◽

10.1161/circ.142.suppl_3.14977 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Alexander Ivanov ◽

Bharat Ravishankar ◽

Rishi Thaker ◽

rachit marwaha ◽

Issa Kutkut

Keyword(s):

Myocardial Infarction ◽

Randomized Clinical Trials ◽

Meta Analysis ◽

Coronary Intervention ◽

Risk Difference ◽

St Elevation Myocardial Infarction ◽

Complete Revascularization ◽

Initial Procedure ◽

Treatment Interaction ◽

St Elevation

Background: Primary Percutaneous Coronary Intervention (PCI) is the preferred treatment for patients presenting with ST-elevation myocardial infarction (STEMI). Despite multiple randomized clinical trials (RCT) best revascularization strategy (RS) in patients with STEMI and multivessel disease (MVD) remains unknown. We aimed to use network meta-analysis to compare currently used approaches. Methods: We searched for RCT comparing RSs in patients with MVD undergoing PCI for STEMI. We identified and compared RCT with arms evaluating at least two of the following approaches: culprit only revascularization (CoR), complete revascularization during initial intervention (CR) and staged procedure with culprit vessel revascularization followed by non culprit significant lesions intervention during the initial hospitalization. Our primary outcome was all-cause mortality. We combined direct and indirect data to perform a network meta-analysis. Results: A total of 7,779 patients from 13 RCT were included in this analysis (Fig. 1). Overall, this is an unbalanced network with only 1 arm comparing CR and SR. Complete revascularization during initial procedure was associated with a significant reduction in mortality with RR 0.47 (0.34; 0.65), p<0.01, when compared to culprit only approach. There was a higher risk of mortality associated with SR, when compared to CR, with RR 1.9 (1.29; 2.82), p<0.01. There was no mortality risk difference between CoR and SR, RR 0.89 (0.72,1.11), p>0.5 (Fig. 2). There was no evidence of a model inconsistency in an overall comparison, p>0.21. There was a design by treatment interaction in SR vs CoR comparison, p<0.01. Conclusion: Complete revascularization during primary PCI in patients presenting with STEMI and MVD was associated with significant mortality reduction when compared to culprit only lesion revascularization. There may be design by treatment interaction limiting comparison of staged and culprit only strategies.

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