IN-HOSPITAL OUTCOME OF OCTOGENARIAN PATIENTS WITH ACUTE ST SEGMENT ELEVATION MYOCARDIAL INFARCTION ABSTRACT

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1 IN-HOSPITAL OUTCOME OF OCTOGENARIAN PATIENTS WITH ACUTE ST SEGMENT ELEVATION MYOCARDIAL INFARCTION Nisar Ahmed, Syed Nauman Ali, Shoaib Abid ABSTRACT Background: Acute myocardial infarction (AMI) is one of e most deadly disease of e cardiovascular origen. Older patients are more likely to have a silent or unrecognized AMI and to develop heart failure, atrial fibrillation, cardiac rupture, and shock, all of which are associated wi increased mortality and a poor prognosis. Objective: To determine e frequency of in-hospital outcome of octogenarians wi acute ST segment elevation Myocardial infarction. Meodology: This cross sectional study was conducted at department of Cardiology, Chaudhary Pervaiz Elahi Institute of Cardiology, Multan from 25 October 20 to 25 April octogenarian patients of acute myocardial infarction were included in e study and clinically followed during hospital stay. The outcome variables included were mortatilty, cardiogenic shock, post MI and arrhyemia. SPSS version 20 was used for data entry and analysis. Results: was observed in 12 (.6%) of our study cases, cardiogenic shock was noted in 47 (33.6%), post MI was noted in 45 (32.1%) and arrhymia was noted in 53 (37.9%) of our study subjects. Conclusion: High frequencies of arrhymia, cardiogenic shock and post MI have been noted in elderly patients in our study. Keywords: Acute Myocardial Infarction, Octogenarian,. INTRODUCTION Myocardial infarction, is e irreversible necrosis 1 of heart muscle secondary to prolonged ischemia. Myocardial infarction is considered part of a spectrum referred to as acute coronary syndrome (ACS). The ACS continuum representing ongoing myocardial ischemia or injury consists of unstable, non ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation 2 myocardial infarction (STEMI). Wi increased life expectancy, e population of e elderly is increasing, and cardiovascular disease is e major cause of mortality and morbidity in is age 3 group. Alough age itself is a definite high risk factor in cardiovascular disease adverse outcomes, ose of extreme age are often excluded 4 from clinical trials of cardiovascular disease. However, e mechanism by which increasing age contributes to mortality remains unknown. In addition, e erapeutic strategies for elderly patients have not been well established. Alough rombolytic erapy has been shown to improve 5 survival in e elderly, but ese guidelines can be strictly applied to very elderly population is unclear, given at octogenarian patients are a very high-risk group wi a high prevalenceof co- JSZMC 20;7(1): Original Article 6 morbidities. Despite e rombolysis and percutaneous coronary intervention (PCI) technology has been developed and progressed wi stride during e past 10 years, but most cardiologist are reluctant to manage elderly patients wi ose more invasive means because of e potential 7 increased risk of dea and complications. In a study done by Yaling et al, found in-hospital mortality of 24.7%, cardiogenic shock 12.3%, arrhymias 6.2% and post-mi in 9.9% octogenarian after rombolytic erapy for acute myocardial infarction. As older age itself is a high risk for adverse outcome after any cardiac event, so is high risk group must need special attention and management plan compared to oer age groups.this study was conducted to determine e frequency of in-hospital outcome of octogenarians wi acute ST segment elevation myocardial infarction. METHODOLOGY This cross sectional study was conducted from 25 October 20 to 25 April 20. After approval from institutional eical review committee, total number of 0 patients of acute ST segment elevation myocardial infarction between 0-9 years of age 1.Department of Cardiology, Ch. Pervez Elahi Institute of Cardiology, Multan, University of Heal Sciences Lahore, Pakistan. Correspondence: Dr. Syed Nauman Ali, Senior Registrar Cardiology, House no. 4, Green wood lane, Shahid colony, MDA Road, Tariqabad, Multan, Pakistan. drnaumanali@yahoo.com Mobile: Received: Accepted: JSZMC Vol

2 bo sexes admitted to e Chaudhry Pervaiz Elahi Institute of Cardiology, emergency department were included. Patients excluded from study were ose wi non-st segment elevation MI, advanced heart failure, history of coronary artery bypass surgery and any contraindication to rombolytic erapy. Informed written consent was taken from each patient after explaining e meods and aims of study. All patients were given rombolytic erapy (Injection Streptokinase 1.5 million units over one hour) and each patient was monitored rough serial ECGs and echocardiography till discharge from e hospital. In hospital outcomes like mortality, cardiogenic shock, arrhymias and post-mi were noted as present or absent. Statistical analysis was performed using SPSS version Mean and standard deviation were calculated for quantitative variables like age and duration of disease. Frequency and percentages were calculated for qualitative variables like gender and in-hospital outcomes, mortality, cardiogenic shock, arrhymias and post-mi. Effect modifiers like age, gender, duration of disease, smoker, hypertension, and diabetes mellitus were controlled rough stratifications. Post-stratification Chi square was applied to see eir effects on e outcome and p value 0.05 was considered as significant. RESULTS Among e 0 study subjects, 99 (70.7%) were male and 41 (29.3%) were female. Mean age of our study cases was 3.34 ± 2.62 years (minimum age was 0 years while maximum was 9 years). Study results have also indicated at majority of our cases were in e range of age groups 0 to 5 years i.e. 120 (5.7%). Mean duration of disease was also inquired from e patients and it was 4.49 ± 2.67 hours (minimum duration was 1 hour while maximum duration of disease was 12 hours). Our study results have indicated at majority of our study subjects. i.e.94 (67.1%) presented between 1 5 hours. Smoking was noted in 62 (44.3%) of cases, hypertension was seen in 67 (47.9%) of cases, diabetes mellitus was noted in 47 (33.6%) of cases. was observed in 12 (.6%) of cases, cardiogenic shocks were noted in 47 (33.6%) of cases, post MI was noted in 45 (32.1%) of cases and arrhymia was noted in 53 (37.9%) of cases. (Table I-III ). Table I: In hospital outcome in cases (n=0) Outcome Frequency Percentage Total Total Total These in-hospital outcomes of octogenarian patients were stratified wi regards to gender, age, smoking, hypertension and diabetes mellitus. (Table II, III, IV, V, VI). Table II: Stratification of In-hospital outcome wi regards to gender(n=0) (n=12) Male (n=99) Gender Female (n=41) JSZMC Vol

3 Table III: Stratification of In-hospital outcome wi regards to age. (n=0) Table IV: Stratification of In-hospital outcome wi regards to Smoking. (n=0) Table V: Stratification of In-hospital outcome wi regards to hypertension.(n=0) (n=12) (n=12) (n=12) Age groups (In years) 0-5 (n=120) Hypertension (n=67) 6-9 (n=20) Smoking (n=62) (n=7) (n=73) Table VI: Stratification of In-hospital outcome wi regards to Diabetes. (n=0) Cardiogeni c (n=12) Diabetes DISCUSSION Wi improvements in heal care, e life expectancy of e elderly population has increased. The proportion of octogenarians in e general 9 population is expected to triple by e year Even ough octogenarians constitute an important high-risk subgroup of patients wi STEMI, ey are frequently under-represented in clinical trials, and advanced age is considered an independent risk factor for e early morbidity and mortality 10,11,12,13 associated wi PCI for STEMI. Poorer outcome is influenced not only by extensive coronary artery disease but also by more complex comorbidities. In addition, elderly patients are considered more likely an younger patients to suffer complications following revascularization 10,, procedures. Octogenarians have significant high-risk baseline demographic and clinical features, such as diabetes, hypertension, renal failure, anemia, cardiogenic shock, cognitive dysfunction, peripheral artery disease, longer door to balloon time, higher baseline brain natriuretic peptide, and higher C- reactive protein levels. Furer, elderly patients not only have preinterventional characteristics at are high risk for major cardiac events, but also have poor interventional characteristics, including tortuous peripheral arteries, more severe diffuse and calcified coronary artery disease, worse interventional success rates, and lower rates of post-procedural TIMI 3 10 blood flow and ST-segment resolution. A total of 0 octogenarians patients after acute ST segment myocardial infarction meeting inclusion JSZMC Vol

4 and exclusion criteria of is study were registered. Of ese 0 study cases, 99 (70.7%) were male. Similar findings were reported by Fan et al, who reported 4% male gender octogenarians in eir study. However, Claussen et al reported 49.6 % male gender in eir study which is quite less an our study results. Mean age of cases was 3.34 ± 2.62 years (minimum age was 0 years while maximum was 9 years). Study results have also indicated at majority of our cases were in e range of age groups 0 to 5 years i.e. 120 (5.7%). Mean duration of disease was 4.49 ± 2.67 hours. Our study results have indicated at majority of our study cases i.e. 94 (67.1%) presented between 1 5 hours. Smoking was noted in 62 (44.3%) of our study cases while Fan et al reported 35.2 % smoking among such patients. The findings of Fan et al, are similar to at of our study results. Claussen et al, reported 13.1 % smoking in eir study which is quite less an our study results. The reason for is quite low smoking rate may be due to e fact at ere were more females in eir study an male patients while our study included more male patients an female. Hypertension was seen in 67 (47.9%) of our study cases, while Fan et al, reported 52.2 % hypertension in ese cases which is similar to at of our study results. Claussen et al, reported 49.1 % hypertension which is similar to at of our findings. Diabetes mellitus was noted in 47 (33.6%) of our study cases. Fan et al, reported 19.4% diabetic patients in eir study, eir frequency of diabetes is bit lower an at of ours. Claussen et al, reported % diabetes in eir study which is less an our study results. was observed in 12 (.6%) of our study cases. Claussen et al, reported mortality in % of e study cases, Fan et al, reported mortality in 2.2% of ese cases. Yaling et al, reported mortality of 24.7% which is quite high an observed in our study. shock is a complication in approximately 5% % of patients presenting wi STEMI, and remains e leading cause of dea 10 after hospitalization. shocks were noted in 47 (33.6%) of our study cases while Yaling et al, reported cardiogenic shock in 12.3 % of ese cases. This finding was quite less an our study results. was noted in 45 (32.1%) of our study cases and Yaling et al, reported in 9.9 % of eir study cases. was noted in 53 (37.9%) of our study cases. Fan et al, reported arrhymia in 19.1 % of eir study cases, which is less an current study. Yaling et al, reported only 9.9 % arrhymia in eir study. CONCLUSION Elderly patients wi acute myocardial infarction have poor clinical outcomes, as far as, and arrhymia,mortality cardiogenic shocks and post MI are concerned. Our study results have indicated at mortality, cardiogenic shocks and post MI were significantly associated wi female gender, was significantly associated wi smoking. REFERENCES 1. Mallinson T. Myocardial Infarction: focus on first aid. Magazine.2010; (): Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al ACCF/AHA focused update incorporated into e ACCF/AHA 2007 guidelines for e management of patients wi unstable /non-st-elevation myocardial infarction: a report of e American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013; 61:e179 e Lo DKY, Chan CK, Wong JT, Leung KF, Yue CS. Outcomes in octogenarians undergoing percutaneous coronary Intervention. Asian J Gerontol Geriatr. 2011; 6: Lee KH, Ahn Y, Kim SS, Rhew SH, Jeong YW, Jang SY, et al. Characteristics, In-Hospital and Long-Term Clinical Outcomes of nagenarian Compared wi Octogenarian Acute Myocardial Infarction Patients. J Korean Med Sci. 20; 29 (4): O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al ACCF/AHA guideline for e management of ST-elevation myocardial infarction: a report of e American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013; 127 (4) : Caballero L, Ruiz-nodar JM, Marin F, Roldan V, Hurtado JA, Valencia J. Oral anticoagulation improves e prognosis of octogenarian patients wi atrial fibrillation undergoing percutaneous coronary intervention and stenting. Ageing 2013; 42: Sakai K, Nagayama S, Ihara K, Ando K, Shirai S, Kondo K, et al. Primary percutaneous coronary intervention for acute myocardial infarction in e JSZMC Vol

5 elderly aged 75 years. Caeter Cardiovasc Interv. 2012; 79: Yaling HAN, Yi LI, Quanming JING, Shouli WANG, Xiaozeng WANG. Comparison of interventional and conservative treatment on inhospital outcomes in elderly patients wi acute myocardial infarction. J Geriatr Cardiol. 2005; 2 (1): Da Costa A, Isaaz K, Faure E, Mourot S, Cerisier A, Lamoud M et al. Clinical characteristics, aetiological factors and long-term prognosis of myocardial infarction wi an absolutely normal coronary angiogram; a 3-year follow-up study of 91 patients. Eur Heart J 2001; 22: Alpert JS. Myocardial infarction wi angiographically normal coronary arteries. A personal perspective. Arch Intern Med 1994; 4: Larson DM, Menssen KM, Sharkey SW,Duval S, Schwartz RS, Harris J, et al. False-positive cardiac caeterization laboratory activation among patients wi suspected ST-segment elevation myocardial infarction. JAMA 2007; 29: Centers for Disease Control and Prevention MMWR series on public heal and aging. MMWR Morb Mortal Wkly Rep ; 52 (6): Gao L, Liu YQ, Xue Q, Feng QZ. Percutaneous coronary intervention in e elderly wi ST-segment elevation myocardial infarction. Clin Interv Aging. 20; 9: Fan G, Fu K, Jin C, Wang X, Han L, Wang H, et al. A medical costs study of older patients wi acute myocardial infarction and metabolic syndrome in hospital. Clin Interv Aging. 20; 10: Claussen PA, Abdelnoor M, Kevakkestad KM, Eritsland J, Halvorsen S. Prevalence of risk factors at presentation and early mortality in patients aged 0 years or older wi ST-segment elevation myocardial infarction. Vasc Heal Risk Manag. 20; 10: JSZMC Vol

Cardiovascular Health Nova Scotia Update to Antiplatelet Sections of the Nova Scotia Guidelines for Acute Coronary Syndromes, 2008.

Cardiovascular Health Nova Scotia Update to Antiplatelet Sections of the Nova Scotia Guidelines for Acute Coronary Syndromes, 2008. ST Elevation Myocardial Infarction (STEMI)-Acute Coronary Syndrome Guidelines: