Primary Percutaneous Coronary Intervention In Nonagenarian Patients With ST Elevation Myocardial Infarction: In-Hospital Mortality And Outcomes At One Year Follow-Up

BACKGROUND Limited information is available about the efficacy and outcomes after primary percutaneous coronary intervention (PPCI) in very elderly patients (pts) with ST Elevation Myocardial Infarction (STEMI). METHODS 23 nonagenarian pts were treated (1% of the total STEMI population underwent P-PCI). We evaluated in-hospital, 6-months and 1 year-mortality in a retrospective analysis of nonagenarian pts admitted at our Department with STEMI and treated with P-PCI from November 2004 and December 2013. A bivariate analysis was carried on with exact Fisher’s test, identifying those variables associated with mortality. Odds ratios (ORs) from univariate logistic regression analyses were performed. RESULTS All pts received aspirin and 300 mg clopidogrel loading dose. Mean age: 91.2 yrs (range 90-96). 65% was women. Mean left ventricular ejection fraction (LVEF) at the admission: 38.9% (23% of pts with LVEF<35%). Advanced Killip class (3-4) at presentation: 10 pts (43%). Baseline characteristic: 13% of pts with prior revascularization, 17.3% prior stroke, 21.7% diabetes, 43% hypertension, 8.6% atrial fibrillation. No dementia (good mental status). Mean renal function evaluated by creatinine clearance measured by the Cockcroft– Gault equation: 38.7 mL/min (range 16.8 – 72.9). Mean hemoglobin value: 13.7 gr/dL. Mean number of vessels treated per pts: 1.04, showing a strategy of treating the culprit vessel only. 3 left main (LM), 8 left anterior descending coronary artery (LAD), 4 circumflex coronary artery, 8 right coronary artery (RCA). The radial approach was performed in 65% (100% of cases from 2012). The proportion of radial to femoral shift was 6%. An average of 1.26 stents per pt were implanted (100% were bare metal stent). In 4 pts we performed P-PCI without stent. No Glycoprotein IIb/IIIa were used. Intra-aortic balloon pump was implanted in 1 pt. The TIMI flow 2-3 post P-PCI was achieved in 78.2% of pts (angiographic success was achieved in 20/23 pts). In 1 pt occurred acute renal failure post P-PCI and in 1 pt occurred major bleeding; no stroke. The overall in-hospital mortality rate was 34.7% (one pt died during the procedure). Cumulative mortality after discharge at 6 months was 14% and at 1 year was 28%. LVEF<30 showed a higher risk of in-hospital mortality and cumulative mortality at 6 months. Killip3 showed a higher risk of in-hospital mortality. LM and LAD showed a higher risk of in-hospital mortality, cumulative mortality at 6 months and at 1 year. CONCLUSIONS Our data suggest that primary P-PCI in nonagenarian pts can be performed with an acceptable bleeding risk. The in-hospital mortality is significant but the cumulative mortality at 6 months and 1 year is low, showed a good success rate of the P-PCI strategy. The radial approach is feasible and safe. The invasive strategy in selected very elderly population should be offered. Further studies are needed to evaluate the benefit of P-PCI versus non P-PCI strategy in the very elderly population.