Age - related treatment strategy and long-term outcome in acute myocardial infarction patients in the PCI era

Petr Kala — 2012-04-25T00:00:00Z

Background: Older age, as a factor we cannot affect, is consistently one of the main negative prognosticvalues in patients with acute myocardial infarction. One of the most powerful factors thatimproves outcomes in patients with acute coronary syndromes is the revascularizationpreferably performed by percutaneous coronary intervention. No data is currently availablefor the role of age in large groups of consecutive patients with PCI as the nearly sole methodof revascularization in AMI patients. The aim of this study was to analyze age-relateddifferences in treatment strategies, results of PCI procedures and both in-hospital and longtermoutcomes of consecutive patients with acute myocardial infarction. Methods: Retrospective multicenter analysis of 3814 consecutive acute myocardial infarction patientsdivided into two groups according to age (1800 patients [less than or equal to] 65 years and 2014 patients > 65years). Significantly more older patients had a history of diabetes mellitus and previousmyocardial infarctions. Results: The older population had a significantly lower rate of coronary angiographies (1726; 95.9%vs. 1860; 92.4%, p < 0.0001), PCI (1541; 85.6% vs. 1505; 74.7%, p < 0.001), achievement ofoptimal final TIMI flow 3 (1434; 79.7% vs. 1343; 66.7%, p < 0.001) and higher rate ofunsuccessful reperfusion with final TIMI flow 0-1 (46; 2.6% vs. 78; 3.9%, p = 0.022). A totalof 217 patients (5.7%) died during hospitalization, significantly more often in the olderpopulation (46; 2.6% vs. 171; 8.5%, p < 0.001). The long-term mortality (data for 2847patients from 2 centers) was higher in the older population as well (5 years survival: 86.1%vs. 59.8%). Though not significantly different and in contrast with PCI, the presence ofdiabetes mellitus, previous MI, final TIMI flow and LAD, as the infarct-related artery, hadrelatively lower impact on the older patients. Severe heart failure on admission (Killip III-IV)was associated with the worst prognosis in the whole group of patients, though itssignificance was higher in the youngers (HR 6.04 vs. 3.14, p = 0.051 for Killip III and 12.24vs. 5.65, p = 0.030 for Killip IV). We clearly demonstrated age as a strong discriminator forthe whole population of AMI patients. Conclusions: In a consecutive AMI population, the older group (>65 years) was associated with a lesspronounced impact of risk factors on long-term outcome. To ascertain the coronary anatomyby coronary angiography and proceed to PCI if suitable regardless of age is crucial in allpatients, though the primary success rate of PCI in the older age is lower. Age, when viewedas a risk factor, was a dominant discriminating factor in all patients.

Choice of generic antihypertensive drugs for the primary prevention of cardiovascular disease - A cost-effectiveness analysis

Torbjørn Wisløff — 2012-04-04T00:00:00Z

Background: Hypertension is one of the leading causes of cardiovascular disease (CVD). A range of antihypertensive drugs exists, and their prices vary widely mainly due to patent rights. The objective of this study was to explore the cost-effectiveness of different generic antihypertensive drugs as first, second and third choice for primary prevention of cardiovascular disease. Methods: We used the Norwegian Cardiovascular Disease model (NorCaD) to simulate the cardiovascular life of patients from hypertension without symptoms until they were all dead or 100 years old. The risk of CVD events and costs were based on recent Norwegian sources. Results: In single-drug treatment, all antihypertensives are cost-effective compared to no drug treatment. In the base-case analysis, the first, second and third choice of antihypertensive were calcium channel blocker, thiazide and angiotensin-converting enzyme inhibitor. However the sensitivity and scenario analyses indicated considerable uncertainty in that angiotensin receptor blockers as well as, angiotensin-converting enzyme inhibitors, beta blockers and thiazides could be the most cost-effective antihypertensive drugs. Conclusions: Generic antihypertensives are cost-effective in a wide range of risk groups. There is considerable uncertainty, however, regarding which drug is the most cost-effective.

Abdominal aortic calcification quantified by the Morphological Atherosclerotic Calcification Distribution (MACD) index is associated with features of the metabolic syndrome

Natasha Barascuk — 2011-12-20T00:00:00Z

Background: Abdominal aortic calcifications (AAC) predict cardiovascular mortality. A new scoring model for AAC, the Morphological Atherosclerotic Calcification Distribution (MACD) index may contribute with additional information to the commonly used Aortic Calcification Severity (AC24) score, when predicting death from cardiovascular disease (CVD). In this study we investigated associations of MACD and AC24 with traditional metabolic-syndrome associated risk factors at baseline and after 8.3 years follow-up, to identify biological parameters that may account for the differential performance of these indices. Methods: Three hundred and eight healthy women aged 48 to 76 years, were followed for 8.3 ± 0.3 years. AAC was quantified using lumbar radiographs. Baseline data included age, weight, blood pressure, blood lipids, and glucose levels. Pearson correlation coefficients were used to test for relationships. Results: At baseline and across all patients, MACD correlated with blood glucose (r2 = 0.1, P< 0.001) and to a lesser, but significant extent with traditional risk factors (p < 0.01) of CVD. In the longitudinal analysis of correlations between baseline biological parameters and the follow-up calcification assessment using radiographs we found LDL-cholesterol, HDL/LDL, and the ApoB/ApoA ratio significantly associated with the MACD (P< 0.01). In a subset of patients presenting with calcification at both baseline and at follow-up, all cholesterol levels were significantly associated with the MACD (P< 0.01) index. AC24 index was not correlated with blood parameters. Conclusion: Patterns of calcification identified by the MACD, but not the AC24 index, appear to contain useful biological information perhaps explaining part of the improved identification of risk of cardiovascular death of the MACD index. Correlations of MACD but not the AC24 with glucose levels at baseline suggest that hyperglycemia may contribute to unique patterns of calcification indicated by the MACD.

Editor's picks

Age - related treatment strategy and long-term outcome in acute myocardial infarction patients in the PCI era

Choice of generic antihypertensive drugs for the primary prevention of cardiovascular disease - A cost-effectiveness analysis

Abdominal aortic calcification quantified by the Morphological Atherosclerotic Calcification Distribution (MACD) index is associated with features of the metabolic syndrome