Immad Sadiq

Revascularization, Stenting, and Outcomes of Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock

Randomized clinical trials have demonstrated a reduction in mortality with early revascularization of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, and recent single-center studies have particularly suggested further benefit for coronary stenting. The purpose of this study was to examine the use of revascularization and coronary stenting for patients with shock from a multicenter, international perspective. Patients with AMI complicated by cardiogenic shock (n = 583) who enrolled between April 1999 and June 2001 were prospectively identified from the large, multinational, observational Global Registry of Acute Coronary Events. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in this group of patients. Cardiac catheterization (52%) and revascularization (43%) were performed in approximately half of the cardiogenic shock patients. Elderly patients (age >/=75 years) comprised 40% of the shock cohort. Regional differences were seen in the use of revascularization, adjunctive medical therapy, and type of revascularization used (coronary stenting). Total hospital mortality was 59%, but case fatality rates ranged from 35% for patients who underwent coronary stenting to 74% for patients who did not undergo any cardiac catheterization. Percutaneous coronary intervention with coronary stenting was the most powerful predictor of hospital survival (odds ratio 3.99, 95% confidence interval 2.41 to 6.62). Thus, cardiogenic shock continues to be a devastating complication of AMI, and relative underuse of a revascularization strategy may be related to the large proportion of elderly patients in this population. In this multinational registry study, coronary stenting was the most powerful independent predictor of hospital survival.

Age-specific differences in the use of thrombolytic therapy and hospital outcomes in patients with acute myocardial infarction: A community-wide perspective

AbstractBackground: Relatively limited information is available about recent, and trends over time, use of thrombolytic therapy in patients of different ages hospitalized with acute myocardial infarction and the association between use of thrombolytic therapy and hospital outcomes. Methods: We conducted an observational study of 5601 residents of the Worcester, Massachusetts, metropolitan area (1990 census = 437,000) with confirmed acute myocardial infarction in all local hospitals during 6 one-year periods between 1990 and 1999. Results: Despite relatively stable use of thrombolytic therapy between 1990 and 1995, decreases in the use of thrombolytic therapy in all patients with acute myocardial infarction were observed in 1997 and 1999. There was a 1.6 fold decrease in the use of thrombolytic therapy between 1990 and 1999 in patients <65 years. Patients 65–74 years (33.7% 1990; 11.7% 1999) and those 75 years and older (10.8% 1990; 6.7% 1999) experienced marked decreases in the receipt of thrombolytic therapy over time. Use of thrombolytic therapy was associated with reduced hospital mortality in each of the four age-specific groups under study (<55, 55–64, 65–74, ≥75) through the degree of benefit on hospital death rates associated with the use of thrombolytic therapy was attenuated after adjustment for additional confounders. Conclusions: Our findings indicate recent declines in the use of thrombolytic therapy in middle-aged and elderly patients with acute myocardial infarction. The impact of thrombolytic therapy on hospital outcomes was observed in each of our age strata under study though the magnitude of absolute and relative benefit varied according to age. Miniabstract. Declines in the use of thrombolytic therapy were observed between 1900 and 1999 in a population-based sample of patients with acute myocardial infarction. Use of thrombolytic therapy was associated with improved hospital survival to varying degrees in each of the age groups under study.

Is primary angioplasty better than thrombolytic therapy in elderly patients with acute myocardial infarction? An insight from the Global Registry of Acute Coronary Events (GRACE)

thrombolytic therapy in elderly patients with AMI in the current era of stents and antithrombotic agents, particularly from a multinational, community-based perspective. Methods and results: Data were evaluated from 2212 AMI patients aged ≥65 years with ST-elevation or LBBB on ECG. All were eligible for standard reperfusion therapy. Of these, 11.4% underwent primary PCI (median delay 121 min, IQR 65, 330 min) and 31.7% received thrombolytic therapy (median delay 40 min, IQR 25, 70 min). Patients who underwent PCI tended to be sicker than those who received thrombolytic therapy, and were more likely to be given clopidogrel, ticlopidine, LMWH and GP IIb/IIIa antagonists.