I. How to reperfuse therapy early in elderly AMI patients
AMI has become a major cause of death in elderly patients, and the GRACE registry study showed that for every 10-year increase in patient age, the mortality rate of AMI increases nearly 1-fold. Elderly AMI patients and their families are prone to refuse emergency percutaneous coronary interventions due to insufficient knowledge of the disease, concerns about the intervention itself and the cost of treatment, and other reasons, missing the best time for treatment with poor prognosis. Therefore, a safe and effective reperfusion treatment strategy should be selected for elderly patients within the optimal time window for AMI, taking into account all factors.
Second, the characteristics of high-grade AMI
1, clinical symptoms and electrocardiographic performance is not typical.
The NRMI registry study showed that 96.3% of AMI patients under 65 years of age had typical ST-segment elevation; only 69.9% of patients ≥ 85 years of age had combined left bundle branch block, but up to 33.8%.
2, prone to serious complications.
In the GUSTO-Ⅰ study, the 30-day mortality rate was 3.0% in patients under 65 years of age with ST-segment elevation myocardial infarction, but was 10 times higher in patients ≥85 years of age, reaching 30.3%.
3. Effective reperfusion therapy is not easily available.
The main reasons are delayed presentation, atypical symptoms, atypical ECG changes or combined contraindications to reperfusion therapy. In addition, there are more complex multi-vessel lesions in elderly AMI patients, difficulty in determining infarct-related arteries, and low percentage of complete revascularization. The willingness of patients and families and the low evidence of STEMI reperfusion therapy studies in elderly patients are also important influencing factors.
4. Emergency PCI may significantly improve prognosis.
In the MITRA study, although the rate of elderly patients receiving reperfusion therapy was significantly lower than the younger group, reperfusion therapy in the elderly group reduced mortality more significantly.
5, emergency PCI is superior to thrombolysis in elderly STEMI patients.
The GUSTO IIb study found that in all age groups, emergency PCI had a better prognosis than thrombolysis, and the 30-day mortality or reinfarction rate was significantly lower in patients aged 70-79 years. In addition, a meta-analysis showed that emergency PCI significantly reduced death in patients older than 70 years compared with thrombolysis. However, reperfusion success rates were lower in older patients over 80 years of age. Although emergency PCI was superior to thrombolysis in older patients, the poor prognosis did not change with increasing age. a subgroup analysis of the GUSTO-IIb study of angioplasty showed that the 30-day mortality or reinfarction rate increased 1.32-fold for each 10-year increase in patient age.
In conclusion, emergency PCI improves the prognosis of elderly STEMI patients and avoids the risk of intracranial hemorrhage associated with thrombolytic therapy; therefore, PCI should be an important modality of choice for reperfusion therapy in elderly patients with indications in cardiac centers where available.
C. Considerations for emergency PCI in elderly patients with AMI
1. PCI in elderly patients is associated with high risk, complications, high mortality and poor prognosis, and physicians should fully communicate with patients’ families.
2. Multiple vascular lesions are common, and only infarct-related vessels are usually treated in the acute phase; if complete revascularization is needed, consider completing the procedure in stages to reduce the risk.
3. minimizing the amount of contrast agent, preferably applying isotonic contrast agent, paying attention to perioperative hydration and protecting renal function.
4. Patients with combined heart failure should consider intra-aortic balloon counterpulsation and be prepared for emergency coronary artery bypass grafting if necessary.
5, combined with peripheral vascular disease is common, attention should be paid to avoid complications such as injury to the peripheral vasculature, and interventional treatment by the long sheath or radial artery route can be considered if necessary.
6, antithrombotic treatment should be highly concerned about the risk of bleeding at the same time, it is recommended to conduct routine bleeding risk assessment for the elderly, strengthen monitoring for patients with higher bleeding risk, balance antithrombotic and bleeding risk, consider the use of new anticoagulant drugs (such as bivalirudin), and apply acid suppressants and gastric mucosal protective agents if necessary.