| BACKGROUND Coronary heart disease (CHD), especially acute coronary syndrome (ACS), is a leading cause of death and disability worldwide. ACS is divided into unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI). With the raising of life quantity, the incidence of ACS is increasing gradually in recent years. In the United States, the incidence of myocardial infarction remains at a high level, about600,000cases of new onset STEMI/NSTEMI and320,000cases of relapse every year. On the treatment of ACS, it has gone through the basic drug treatment, coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA). In the last30years, with the development of coronary recanalization therapy technology and medications, the mortality and morbidity in ACS patients have been decreased significantly. Because there is a big difference between the best clinical practices and optimal clinical treatment strategy, some patients have been not received the best treatment. CABG surgery is difficult to be promoted a wide range of applications due to trauma and narrower indications. With the improvement of equipment, the accumulation of experience and the improvement of research level, remarkable advancements in PCI technology have taken place in the past decade and undergoing PCI is rising.Emergency PCI can reduce mortality and improve the heart function significant-1y in ACS patients. With the improvement of people’s living standards and life expectancy in China, the age of ACS patients is becoming younger and younger and the proportion of elderly individuals with ACS is growing. In the United States, over60%of acute myocardial infarction occur in patients65years of age or older, and approximately one third occur in persons over age75. However, there are few large-scale clinical studies for elderly (≥75years) ACS patients. Although clinicians and cardiovascular researchers have begun to pay attention to this area, but it is difficult for the elderly patients to be enrolled in clinical studies because the elderly patients with ACS are often affected by numerous disorders, multiple or single organ dysfunction, socioeconomic status and drug interactions. These problems above have also led to be quite complicated in treatment of elderly ACS patients. It is unclear whether revascularization treatment can be used for elderly ACS patients due to the lack of large-scale clinical studies of revascularization in elderly ACS patients. Currently, the diagnosis, treatment and the care in elderly ACS patients is still clinical challenges. To determine the best treatment for the elderly ACS patients, doctors often need to combine some previously research results with their own experience.This study was to evaluate the safety of emergency PCI in elderly ACS patients by comparing the clinical characteristics and the effect of emergency PCI between elderly patients older than75years and non-elderly patient yonger than75years.OBJECTIVEThe aim of our study was to determine the clinical characteristics and to evaluate the efficacy of emergency PCI in the elderly (≥75years) compared with those in younger patients (<75years).METHODS The study included213consecutive patients with ACS treated in Nanjing General Hospital of Nanjing Military Command from January2011to December2012. Analyses were performed retrospectively. The patients were separated into2groups according to age. The elderly group consisted of57patients aged75or over and the non-elderly group (control group) consisted of156patients aged below75years. The clinical symptoms, risk factors, extent of coronary artery stenosis, success rate of emergency PCI, postoperative complications and mortality during hospitalize-tion were analyzed between the2groups.RESULTS1) The baseline characteristics of patients in2groups were as follow:In the elderly patients (78.96±3.36years), male to female ratio was30/27and atypical to typical chest pain ratio was10/47(Atypical chest pain accounted for17.5%). The average time from pain to door was6.0hours and the average time from door to ballon was0.7hours in elderly group. There were20elderly patients with heart failure,13cases of Killip II grade (22.8%) and7cases of Killip IE/IVgrade (12.3%). Serum creatinine was108.00±62.05mmol/L on admission in elderly group. In the non-elderly patients (58.83±9.99years), male to female ratio was130/26and atypical to typical chest pain ratio was18/138(Atypical chest pain accounted for13.0%). The average time from pain to door was5.0hours and the average time from door to ballon was1.0hours in non-elderly group. There were20non-elderly patients with heart failure,14cases of Killip II grade (9.0%) and6cases of Killip IE/IV grade (3.8%). Serum creatinine was81.48±36.42mmol/L on admission in non-elderly group. In elderly patients there were more women (p<0.05) and more patients with renal insufficiency (p<0.05) and heart failure (p<0.05). Atypical chest pain was reported more frequently in the elderly, but the difference was not statistically significant. 2) The risk factors of coronary heart disease in2groups were as follow:In the elderly ACS patients, the incidence of smoking, hypertension, diabetes, hyperlipid-emia, previously diagnosed myocardial infarction and cerebral infarction was22.8%,66.7%,22.8%,67.3%,1.8%and12.3%respectively. In the non-elderly ACS patients, the incidence of cigarette smoking, hypertension, diabetes, hyperlipidemia, myocard-ial infarction and cerebral infarction history was57.1%,51.9%,16.7%,64.4%,1.9%and6.4%respectively. In elderly group there were more patients with hypertension (p <0.05) and with cigarette smoking (p<0.05). Diabetes, hyperlipidemia and previously diagnosed cerebral infarction were reported more frequently in the elderly, but the difference was not statistically significant.3) The coronary artery lesion severity and treatment differences in2groups were as follow:In the elderly ACS patients, the incidence of multi-vessel disease, diffuse, total occlusion was91.9%,19.3%and68.4%respectively. The median of Gensini score was58.0(40.0/81.0) and the number of stent was1.02±0.69in every elderly patient. The application rates of low molecular weight heparin, tirofiban, intra-aortic balloon pump (IABP) and temporary pacemaker in elderly patients were75.4%,91.2%,7.0%and7.0%respectively. In the non-elderly ACS patients, the incidence of multi-vessel disease, diffuse, total occlusion was84.9%,13.5%and64.1%respectively. The median of Gensini score was47.8(32.3/85.4) and the number of stent was1.02±0.57in every non-elderly patient. The application rates of low molecular weight heparin, tirofiban, intra-aortic balloon pump (IABP) and temporary pacemaker in non-elderly patient were69.9%,84.6%,1.9%and1.9%respectively. The diffuse, multi-branch, total occlusion lesion was reported more frequently in the elderly, but the difference was not statistically significant. There was no difference in treatment strategy between the elderly and non-elderly group.4) The laboratory test results of patients in2groups were as follow:Serum Scr, TC, HDL-C, LDL-C, TG, G, CK, CK-MB in the elderly ACS patients during hospitalization was108.00±62.05umol/L,4.39±0.89mmol/L,1.06±0.33mmol/L,2.73±0.78mmol/L,1.36±0.66mmol/L,7.55±3.61mmol/L,1213.54±961.58U/L and144.37±125.73U/L respectively. Serum Scr, TC, HDL-C, LDL-C, TG, G, CK, CK-MB in the non-elderly ACS patients during hospitalization was81.48±36.42umol/L,4.45±1.13mmol/L,1.07±0.25mmol/L,2.96±0.96mmol/L,1.50±1.07mmol/L,6.76±2.83mmol/L,1555.75±1716.26U/L and154.64±174.31U/L respectively. The median of CTnT and CTnl in elderly ACS patients was2.0ug/L (1.0/3.2) and18.0ug/L (1.1/42.4) respectively. The median of CTnT and CTnI in non-elderly ACS patients was2.0ug/L (0.5/3.4) and20.7ug/L (1.5/49.4) respectively. The Scr level in the elderly ACS patients was significantly higher than those in the non-elderly group (p<0.05), but there were no differences in the other test indicators between the two groups.5) The efficacy and complications of emergency PCI in2groups were as follow: There was no significantly difference in successful rate of emergency PCI between two groups, elderly93.0%, and non-elderly98.1%. There was no statistical significance in the difference of serum creatinine before and after emergency PCI between the two groups, elderly3.00±10.44umol/L and non-elderly4.48±8.98umol/L. In elderly group, the rate of recurrent angina, heart failure, malignant arrhythmia, CABG and death was5.3%,22.8%,8.8%,0.0%and7.0%respectively. In the non-elderly ACS patients, the rate of recurrent angina, heart failure, malignant arrhythmia, surgical complications and death was7.1%,17.9%,1.3%,2.6%and1.9%respectively. There was no significantly difference in the hospitalization time between two groups, elderly8.9±2.2days and non-elderly8.9±3.6days. There was more patients with malignant arrhythmia after PCI during hospitalization in elderly group (p<0.05). There are no statistically differences in rate of recurrent angina, heart failure, CABG and mortality between the two groups.CONCLUSION1) Our observations confirm the differences in the clinical picture of ACS in the elderly as described previously. In elderly patients there are more women, more patients with hypertension and with renal insufficiency2) Compared with in the non-elderly patients, the coronary lesions is more complex in the elderly group, but there is no significant difference in the successful rate of emergency PCI and the mortality between the two groups. Therefore, emergency PCI in elderly ACS patients is safe and effective. |
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