Introduction: Older patients with acute myocardial infarctions are often underrepresented in clinical trials. However, due to demographic changes, elderly represent a patient group of increasing importance. Aim of the present study was to investigate, how incidence rates, infarction severity and treatment strategies of ST-elevation-myocardial infarctions (STEMI) in octogenarians and nonagenarians have changed during the last two decades and to assess how gender and interventional results impacted prognosis.
Methods: All patients, admitted with STEMI between 2006 and 2022 ≥80 yrs. of age were analyzed. Univariate comparisons were complemented with multivariate models adjusted for confounders.
Results: Of a total of 12088 STEMI-patients, 1703 (14.1 %) were octo- or nonagenarians. The proportion of patients ≥80 yrs. of age increased from 12.5% 2006-2007 to 16.8% in 2020-2022; p(for trend)<0.01. The number of admissions/month increased from 7.9 STEMIs/month in 2006-2007 to 11.2 STEMIs/month in 2020-2022. At the same time, patients ≥80 yrs. of age were more likely to present with STEMI complicated by cardiogenic shock (2006-2007: 15.1% to 2020-2022: 19.4 %; p(for trend)<0.01) and to be treated with primary percutaneous coronary intervention (PCI): 2006-2007: 72.5% to 2020-2022: 91.2%; p(for trend)<0.01.
Of all patients ≥80 yrs. 918 (53.9%) were women and 785 (46.1%) men. When comparing women to men, rates of cardiogenic shock were similar (16.8% vs. 18.1 %, p=0.51) as were rates of primary PCI (87.3% vs. 87.1 %, p=0.92). However, rates of absence of typical chest pain were higher in women compared to men (18.5% vs. 12.9%, p<0.01) and women showed a higher 30-day-mortality (29.4% vs. 24.3%, p=0.035) and a trend towards a higher 1 year-mortality (41.7% vs. 36.9%, p=0.06). 5-year-mortality rates were again similar between genders (63.5% vs. 63.6%, p=0.9).
When focusing on the entire cohort and comparing the impact of a successful PCI by age group, it could be shown that the beneficial impact of a successful PCI with TIMI-3-flow was independent of age and other confounders and that the greatest absolute risk reduction (ARR) in 30-day-mortality could be seen for octogenarians or nonagenarians (table).
Table: Impact of TIMI-3-flow post PCI on 30-day-mortality in STEMI-patients stratified by age
| |
Age <60 yrs. |
Age 60-79 yrs. |
Age ≥80 yrs. |
| 30-day-mort. with TIMI 3 (%) |
3.1 |
8.9 |
22.5 |
| 30 day-mort. without TIMI 3 (%) |
13.3 |
25.3 |
40.3 |
| ARR (%) |
10.1 |
16.3 |
17.7 |
| Adjusted HR (95% CI)* |
0.26 (0.18-0.38) |
0.39 (0.31-0.49) |
0.57 (0.44-0.75) |
| Significance p |
<0.01 |
<0.01 |
<0.01 |
*Multivariate model adjusted for age, gender, diabetes mellitus, peak CK, multivessel disease
Conclusions: This registry data shows that during the last 17 years, STEMI-numbers in patients ≥80 years increased by more than 40% with higher rates of concomitant cardiogenic shock. While elderly women compared to men showed a worse short-term prognosis, 5-year-mortality rates were similar between genders. Over time, rates of primary PCI were increasing in the elderly with STEMI. Compared to other age groups, a TIMI-3-flow post PCI was associated with the largest absolute risk reduction (ARR) in 30-day-mortality for the elderly resulting in a number-to-treat (NNT) of 5.6.
