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Decreased usage and increased effectiveness of percutaneous coronary intervention in complex older patients with acute coronary syndromes
  1. Mauro Di Bari1,
  2. Daniela Balzi2,
  3. Stefania Fracchia1,
  4. Alessandro Barchielli2,
  5. Francesco Orso1,
  6. Andrea Sori3,
  7. Simona Spini4,
  8. Nazario Carrabba5,
  9. Giovanni M Santoro6,
  10. Gian Franco Gensini7,
  11. Niccolò Marchionni1,
  12. For the Acute Myocardial Infarction in Florence 2 (AMI Florence-2) Working Group
  1. 1Department of Experimental and Clinical Medicine, Research Unit of Medicine of Aging, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
  2. 2Epidemiology Unit, Local Health Unit 10, Florence, Italy
  3. 3Department of Cardiovascular Medicine, Unit of Internal Medicine and Cardiology, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
  4. 4Cardiology Unit, Santa Maria Nuova Hospital, Local Health Unit 10, Florence, Italy
  5. 5Department of Cardiovascular Medicine, Cardiology Unit 1, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
  6. 6Cardiology Unit, Nuovo San Giovanni di Dio Hospital, Local Health Unit 10, Florence, Italy
  7. 7Department of Experimental and Clinical Medicine, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Fondazione Don Carlo Gnocchi IRCCS, Florence Italy
  1. Correspondence to Professor Mauro Di Bari, Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Viale Pieraccini, 18, Florence 50139, Italy; mauro.dibari{at}unifi.it

Abstract

Background Application of percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) is suboptimal in older frail individuals. This study was conducted to verify if background risk is a risk factor for underuse and diminished effectiveness of PCI in older patients.

Methods An observational cohort study was conducted using data from the Acute Myocardial Infarction in Florence 2 registry, including all ACS hospitalised in 1 year in the area of Florence, Italy. Patients aged 75+ years were selected, whose background risk was stratified with the Silver Code (SC), a validated tool predicting mortality based upon administrative data. Multivariable OR for PCI application and HR for 1-year mortality by PCI usage were calculated.

Results In 698 patients (358 women, mean age 83 years), of whom 176 had ST-segment elevation myocardial infarction (STEMI), for each point increase in SC score the odds for application of PCI decreased by 11%, whereas the hazard of 1-year mortality increased by 10%, adjusting for positive and negative predictors. PCI reduced 1-year mortality progressively more with increasing SC, with HR (95% CI) of 0.8 (0.19 to 1.21), 0.41 (0.18 to 0.45), 0.41 (0.23 to 0.74) and 0.26 (0.14 to 0.48) for SC of 0–3, 4–6, 7–10 and 11+.

Conclusions Application of PCI in older ACS patients decreased with increasing background risk. This therapeutic attitude could not be justified by decreasing effectiveness of PCI in more compromised patients: conversely, application of PCI was associated with a long-term survival advantage that increased progressively with background risk, as expressed by SC.

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