Advertisement

Mortality in Patients With ST-Segment Elevation Myocardial Infarction Who Do Not Undergo Reperfusion

      Reperfusion therapy reduces mortality in patients presenting with ST-segment elevation myocardial infarctions (STEMI). However, some patients may not receive thrombolytic therapy or undergo primary percutaneous coronary intervention. The decision making and clinical outcomes of these patients have not been well described. In this study, 139 patients were identified from a total of 1,126 patients with STEMI who did not undergo reperfusion therapy at a high-volume percutaneous coronary intervention center from October 2006 to March 2011. Clinical data, reasons for no reperfusion, management, and mortality were obtained by chart review. The mean age was 80 ± 13 years (61% women, 31% diabetic, and 37% known coronary artery disease). Of the 139 patients, 72 (52%) presented with primary diagnoses other than STEMI, and 39 (28%) developed STEMI >24 hours after admission. The most common reasons for no reperfusion were advanced age, co-morbid conditions, acute or chronic kidney injury, delayed presentation, advance directives precluding reperfusion, patient preference, and dementia. Eighty-four patients (60%) had ≥3 reasons for no reperfusion. Factors associated with hospital mortality were cardiogenic shock, intubation, and advance directives prohibiting reperfusion after physician consultation. In hospital and 1-year mortality were 53% and 69%, respectively. In conclusion, at a high-volume percutaneous coronary intervention center, most patients presenting with STEMI underwent immediate catheterization. The decision for no reperfusion was multifactorial, with advanced age reported as the most common factor. Outcomes were poor in this population, and fewer than half of these patients survived to hospital discharge.
      To read this article in full you will need to make a payment

      References

        • Antman E.M.
        • Anbe D.T.
        • Armstrong P.W.
        • Bates E.R.
        • Green L.A.
        • Hand M.
        • Hochman J.S.
        • Krumholz H.M.
        • Kushner F.G.
        • Lamas G.A.
        • Mullany C.J.
        • Ornato J.P.
        • Pearle D.L.
        • Sloan M.A.
        • Smith Jr, S.C.
        • Alpert J.S.
        • Anderson J.L.
        • Faxon D.P.
        • Fuster V.
        • Gibbons R.J.
        • Gregoratos G.
        • Halperin J.L.
        • Hiratzka L.F.
        • Hunt S.A.
        • Jacobs A.K.
        ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction).
        Circulation. 2004; 110: 588-636
        • Pollack Jr, C.V.
        • Antman E.M.
        • Hollander J.E.
        2007 focused update to the ACC/AHA guidelines for the management of patients with ST-segment elevation myocardial infarction: implications for emergency department practice.
        Ann Emerg Med. 2008; : 344-355
        • Kushner F.G.
        • Hand M.
        • Smith Jr, S.C.
        • King III, S.B.
        • Anderson J.L.
        • Antman E.M.
        • Bailey S.R.
        • Bates E.R.
        • Blankenship J.C.
        • Casey Jr, D.E.
        • Green L.A.
        • Hochman J.S.
        • Jacobs A.K.
        • Krumholz H.M.
        • Morrison D.A.
        • Ornato J.P.
        • Pearle D.L.
        • Peterson E.D.
        • Sloan M.A.
        • Whitlow P.L.
        • Williams D.O.
        2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2009; 54: 2205-2241
        • Barron H.V.
        • Bowlby L.J.
        • Breen T.
        • Rogers W.J.
        • Canto J.G.
        • Zhang Y.
        • Tiefenbrunn A.J.
        • Weaver W.D.
        Use of reperfusion therapy for acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2.
        Circulation. 1998; 97: 1150-1156
        • Forman D.E.
        • Chen A.Y.
        • Wiviott S.D.
        • Wang T.Y.
        • Magid D.J.
        • Alexander K.P.
        Comparison of outcomes in patients aged <75, 75 to 84, and >/= 85 years with ST-elevation myocardial infarction (from the ACTION Registry-GWTG).
        Am J Cardiol. 2010; 106: 1382-1388
        • Schoenenberger A.W.
        • Radovanovic D.
        • Stauffer J.C.
        • Windecker S.
        • Urban P.
        • Eberli F.R.
        • Stuck A.E.
        • Gutzwiller F.
        • Erne P.
        Age-related differences in the use of guideline-recommended medical and interventional therapies for acute coronary syndromes: a cohort study.
        J Am Geriatr Soc. 2008; 56: 510-516
        • Kyriakides Z.S.
        • Kourouklis S.
        • Kontaras K.
        Acute coronary syndromes in the elderly.
        Drugs Aging. 2007; 24: 901-912
        • Boucher J.M.
        • Racine N.
        • Thanh T.H.
        • Rahme E.
        • Brophy J.
        • LeLorier J.
        • Theroux P.
        Age-related differences in in-hospital mortality and the use of thrombolytic therapy for acute myocardial infarction.
        CMAJ. 2001; 164: 1285-1290
        • Holmes D.R.
        • White H.D.
        • Pieper K.S.
        • Ellis S.G.
        • Califf R.M.
        • Topol E.J.
        Effect of age on outcome with primary angioplasty versus thrombolysis.
        J Am Coll Cardiol. 1999; 33: 412-419
        • Wagner G.S.
        • Macfarlane P.
        • Wellens H.
        • Josephson M.
        • Gorgels A.
        • Mirvis D.M.
        • Pahlm O.
        • Surawicz B.
        • Kligfield P.
        • Childers R.
        • Gettes L.S.
        • Bailey J.J.
        • Deal B.J.
        • Hancock E.W.
        • Kors J.A.
        • Mason J.W.
        • Okin P.
        • Rautaharju P.M.
        • van Herpen G.
        AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology.
        Circulation. 2009; 119: e262-e270
        • Kligfield P.
        • Gettes L.S.
        • Bailey J.J.
        • Childers R.
        • Deal B.J.
        • Hancock E.W.
        • van Herpen G.
        • Kors J.A.
        • Macfarlane P.
        • Mirvis D.M.
        • Pahlm O.
        • Rautaharju P.
        • Wagner G.S.
        • Josephson M.
        • Mason J.W.
        • Okin P.
        • Surawicz B.
        • Wellens H.
        Recommendations for the standardization and interpretation of the electrocardiogram: part I: the electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology.
        Circulation. 2007; 115: 1306-1324
        • Sgarbossa E.B.
        • Pinski S.L.
        • Barbagelata A.
        • Underwood D.A.
        • Gates K.B.
        • Topol E.J.
        • Califf R.M.
        • Wagner G.S.
        • GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators
        Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block.
        N Engl J Med. 1996; 334: 481-487
        • Shlipak M.G.
        • Lyons W.L.
        • Go A.S.
        • Chou T.M.
        • Evans G.T.
        • Browner W.S.
        Should the electrocardiogram be used to guide therapy for patients with left bundle-branch block and suspected myocardial infarction?.
        JAMA. 1999; 281: 714-719
        • Dzavik V.
        • Sleeper L.A.
        • Cocke T.P.
        • Moscucci M.
        • Saucedo J.
        • Hosat S.
        • Jiang X.
        • Slater J.
        • LeJemtel T.
        • Hochman J.S.
        Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry.
        Eur Heart J. 2003; 24: 828-837
        • Mehta R.L.
        • Kellum J.A.
        • Shah S.V.
        • Molitoris B.A.
        • Ronco C.
        • Warnock D.G.
        • Levin A.
        Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury.
        Crit Care. 2007; 11: R31
        • Levey A.S.
        • Coresh J.
        • Balk E.
        • Kausz A.T.
        • Levin A.
        • Steffes M.W.
        • Hogg R.J.
        • Perrone R.D.
        • Lau J.
        • Eknoyan G.
        National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification.
        Ann Intern Med. 2003; 139: 137-147
        • Ancestry.com
        Social Security Death Index.
        Ancestry.com Operations, Inc., Provo, Utah2011
        • ISIS-2 (Second International Study of Infarct Survival) Collaborative Group
        Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2.
        Lancet. 1988; 2: 349-360
        • Shah P.
        • Najafi A.H.
        • Panza J.A.
        • Cooper H.A.
        Outcomes and quality of life in patients ≥85 years of age with ST-elevation myocardial infarction.
        Am J Cardiol. 2009; 103: 170-174
        • Valente S.
        • Lazzeri C.
        • Salvadori C.
        • Chiostri M.
        • Giglioli C.
        • Poli S.
        • Gensini G.F.
        Effectiveness and safety of routine primary angioplasty in patients aged > or = 85 years with acute myocardial infarction.
        Circ J. 2008; 72: 67-70
        • White H.D.
        • Barbash G.I.
        • Califf R.M.
        • Simes R.J.
        • Granger C.B.
        • Weaver W.D.
        • Kleiman N.S.
        • Aylward P.E.
        • Gore J.M.
        • Vahanian A.
        • Lee K.L.
        • Ross A.M.
        • Topol E.J.
        Age and outcome with contemporary thrombolytic therapy.
        Circulation. 1996; 94: 1826-1833
        • Maggioni A.P.
        • Maseri A.
        • Fresco C.
        • Franzosi M.G.
        • Mauri F.
        • Santoro E.
        • Tognoni G.
        • Investigators of the Gruppo Italiano per lo Studio Della Sopravvivenza Nell'Infarto Miocardico (GISSI-2)
        Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis.
        N Engl J Med. 1993; 329: 1442-1448
        • de Lemos J.A.
        • Morrow D.A.
        • Gibson C.M.
        • Murphy S.A.
        • Rifai N.
        • Tanasijevic M.
        • Giuliano R.P.
        • Schuhwerk K.C.
        • McCabe C.H.
        • Cannon C.P.
        • Antman E.M.
        • Braunwald E.
        • TIMI 14 Investigators
        Early noninvasive detection of failed epicardial reperfusion after fibrinolytic therapy.
        Am J Cardiol. 2001; 88: 353-358
        • Zahn R.
        • Schweppe F.
        • Zeymer U.
        • Schiele R.
        • Kai Gitt A.
        • Mark B.
        • Frilling B.
        • Seidl K.
        • Winkler R.
        • Heer T.
        • Schneider S.
        • Senges J.
        Reperfusion therapy for acute ST-elevation and non ST-elevation myocardial infarction: what can be achieved in daily clinical practice in unselected patients at an interventional center?.
        Acute Card Care. 2009; 11: 92-98
        • Roe M.T.
        • Messenger J.C.
        • Weintraub W.S.
        • Cannon C.P.
        • Fonarow G.C.
        • Dai D.
        • Chen A.Y.
        • Klein L.W.
        • Masoudi F.A.
        • McKay C.
        • Hewitt K.
        • Brindis R.G.
        • Peterson E.D.
        • Rumsfeld J.S.
        Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention.
        J Am Coll Cardiol. 2010; 564: 254-263