Baseline Comorbidities and Treatment Strategy in Elderly Patient
Background: Cardiogenic shock (CGS) historically results in high inhospital mortality, particularly in elderly patients. Factors that contribute to increased mortality and treatment strategies that improve short- and long-term outcomes in patients with CGS remain to be established.
Methods: The study consisted of 1263 consecutive patients with acute myocardial infarction admitted from Olmsted County, Minn, during the period 1988 to 2000; of these, 73 (6%) developed cardiogenic shock. Short- and long-term mortality was compared between the elderly and younger populations in both shock and nonshock groups.
Results: In patients with acute myocardial infarction, age of ≥65 years was associated with increased long-term mortality for nonshock patients (unadjusted relative risk [RR] 5.23, 95% CI 4.10–6.67, P < .001) and to a lesser degree in patients with cardiogenic shock (unadjusted RR 2.02, 95% CI 1.12–3.65, P = .02). Among cardiogenic shock patients, estimated survival at 1 and 5 years for elderly patients was 38% and 24%, respectively, and in younger patients, 57% and 52%, respectively. When adjusted for confounding variables, elderly noncardiogenic shock patients had significantly increased long-term mortality (adjusted RR 4.38, 95% CI 3.42–5.61, P < .001) compared to younger nonshock patients. In contrast, elderly patients with cardiogenic shock demonstrated a weaker trend toward worse outcomes (adjusted RR 1.80, 95% CI 1.00–3.27, P = .051) compared to younger patients with shock.
Conclusions: The relationship between age and long-term mortality is stronger among patients who do not develop cardiogenic shock. Advanced age was not found to be as strong a risk factor for survival in patients with cardiogenic shock; comorbidities and less aggressive treatment appear to be the major factors resulting in poor outcomes in the elderly patient with cardiogenic shock.
Cardiogenic shock (CGS) occurs in 6% to 8% of patients with acute myocardial infarction (AMI) and carries an inhospital mortality rate of >60%. Various aspects of CGS have been studied in an attempt to better understand the etiologies, risk factors and management strategies that could result ultimately in improved survival.
In the past, numerous studies have elucidated risk factors for increased mortality in patients with AMI and CGS. Patients who develop CGS have a poorer prognosis if they are older, develop shock within 24 hours of admission, have a left main coronary artery or saphenous vein graft related infarct, have mechanical complications (acute severe mitral regurgitation or ventricular septal rupture), or have a non-ST–segment elevation AMI.
Several studies have also explored the beneficial role of different interventions in the setting of AMI complicated by CGS. In the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial registry, intra-aortic balloon counterpulsation (IABP) and thrombolytic therapy were shown to contribute to a decreased mortality in CGS. Early revascularization with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG) also has been shown to have a positive impact on survival in Global Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I), SHOCK, and several other clinical studies. The benefit of revascularization generally was present, however, in patients <65 years of age.
Clinical trails often have had difficulty assessing therapies in the elderly because the inclusion criteria of many trials precludes participation of the elderly.
We sought to elucidate some of the factors in a nonselected, community-based population that contribute to increased mortality in patients with CGS and identify possible strategies to improve outcome in this high-risk group. We hypothesized that differences in age (primary), along with baseline patient characteristics and treatment selection (secondary) would impact survival in the AMI-CGS cohort and provide a valid basis for study.
Background: Cardiogenic shock (CGS) historically results in high inhospital mortality, particularly in elderly patients. Factors that contribute to increased mortality and treatment strategies that improve short- and long-term outcomes in patients with CGS remain to be established.
Methods: The study consisted of 1263 consecutive patients with acute myocardial infarction admitted from Olmsted County, Minn, during the period 1988 to 2000; of these, 73 (6%) developed cardiogenic shock. Short- and long-term mortality was compared between the elderly and younger populations in both shock and nonshock groups.
Results: In patients with acute myocardial infarction, age of ≥65 years was associated with increased long-term mortality for nonshock patients (unadjusted relative risk [RR] 5.23, 95% CI 4.10–6.67, P < .001) and to a lesser degree in patients with cardiogenic shock (unadjusted RR 2.02, 95% CI 1.12–3.65, P = .02). Among cardiogenic shock patients, estimated survival at 1 and 5 years for elderly patients was 38% and 24%, respectively, and in younger patients, 57% and 52%, respectively. When adjusted for confounding variables, elderly noncardiogenic shock patients had significantly increased long-term mortality (adjusted RR 4.38, 95% CI 3.42–5.61, P < .001) compared to younger nonshock patients. In contrast, elderly patients with cardiogenic shock demonstrated a weaker trend toward worse outcomes (adjusted RR 1.80, 95% CI 1.00–3.27, P = .051) compared to younger patients with shock.
Conclusions: The relationship between age and long-term mortality is stronger among patients who do not develop cardiogenic shock. Advanced age was not found to be as strong a risk factor for survival in patients with cardiogenic shock; comorbidities and less aggressive treatment appear to be the major factors resulting in poor outcomes in the elderly patient with cardiogenic shock.
Cardiogenic shock (CGS) occurs in 6% to 8% of patients with acute myocardial infarction (AMI) and carries an inhospital mortality rate of >60%. Various aspects of CGS have been studied in an attempt to better understand the etiologies, risk factors and management strategies that could result ultimately in improved survival.
In the past, numerous studies have elucidated risk factors for increased mortality in patients with AMI and CGS. Patients who develop CGS have a poorer prognosis if they are older, develop shock within 24 hours of admission, have a left main coronary artery or saphenous vein graft related infarct, have mechanical complications (acute severe mitral regurgitation or ventricular septal rupture), or have a non-ST–segment elevation AMI.
Several studies have also explored the beneficial role of different interventions in the setting of AMI complicated by CGS. In the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial registry, intra-aortic balloon counterpulsation (IABP) and thrombolytic therapy were shown to contribute to a decreased mortality in CGS. Early revascularization with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG) also has been shown to have a positive impact on survival in Global Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I), SHOCK, and several other clinical studies. The benefit of revascularization generally was present, however, in patients <65 years of age.
Clinical trails often have had difficulty assessing therapies in the elderly because the inclusion criteria of many trials precludes participation of the elderly.
We sought to elucidate some of the factors in a nonselected, community-based population that contribute to increased mortality in patients with CGS and identify possible strategies to improve outcome in this high-risk group. We hypothesized that differences in age (primary), along with baseline patient characteristics and treatment selection (secondary) would impact survival in the AMI-CGS cohort and provide a valid basis for study.
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