Download a very elderly woman experiencing two episodes of acute

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CASE REPORT
A VERY ELDERLY WOMAN EXPERIENCING TWO
EPISODES OF ACUTE MYOCARDIAL INFARCTION TREATED BY
PERCUTANEOUS CORONARY INTERVENTION: A CASE
REPORT AND LITERATURE REVIEW
Li-Chin Sung1,2*, Ji-Hung Wang2,3
1
Division of Cardiovascular Medicine, Taipei Medical University – Shuang-Ho Hospital, Taipei, 2Division of Cardiology,
Department of Internal Medicine, Buddhist Tzu Chi General Hospital and 3Tzu Chi University, Hualien, Taiwan.
SUMMARY
Advanced age is associated with poor outcome among patients with acute myocardial infarction (AMI). It
appears that elderly patients are treated more conservatively because of multiple comorbidities and higher
risk of further invasive therapy. Reperfusion therapy for AMI may improve survival, and previous studies have
shown that patients receiving percutaneous coronary intervention (PCI) have better clinical outcomes than
those given thrombolytic therapy. We report our experience with a 96-year-old woman with anteroseptal wall
ST-segment elevation myocardial infarction successfully treated with primary PCI. One stent was implanted in
the left anterior descending artery occlusive lesion. The patient survived and was discharged from the hospital
7 days later. She received optimal medical therapy and had no major adverse cardiac events within 1 year.
Unfortunately, the patient had non-ST-segment elevation myocardial infarction 18 months later. We discussed
with her family about the risk/benefit ratio of PCI, and they agreed with the procedure. We performed PCI successfully and the patient was discharged 5 days later. No major adverse cardiac events occurred within 4 months.
In very elderly patients without multiple comorbidities, PCI is safe for AMI and effective in shortening hospital
stay, reducing in-hospital and short-term mortality. We also discuss our strategy for this very elderly patient and
the present therapy for AMI in nonagenarians. [International Journal of Gerontology 2010; 4(3): 148–153]
Key Words: elderly, myocardial infarction, percutaneous transluminal coronary angioplasty
Introduction
The number of very elderly (aged 90 years or older)
patients is progressively increasing1. Patients with acute
myocardial infarction (AMI) in this age group have a
*Correspondence to: Dr Li-Chin Sung, Division of
Cardiovascular Medicine, Taipei Medical University –
Shuang-Ho Hospital, No. 291, Jhongjheng Road,
Jhonghe City, Taipei County 235, Taiwan.
E-mail: [email protected]
Accepted: June 23, 2009
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high mortality because elderly patients have more late
presentations, comorbidities, congestive heart failure,
presence of acute coronary syndrome, and complex
coronary arterial anatomy than their younger counterparts1. We report a patient who had two episodes of AMI
successfully treated with percutaneous coronary intervention (PCI). The patient survived without any major
adverse cardiac events (composite of death, Q-wave
myocardial infarction, and target vessel revascularization) before and after hospital discharge. We review the
present literature regarding appropriate therapy for
nonagenarians with AMI.
International Journal of Gerontology | September 2010 | Vol 4 | No 3
© 2010 Taiwan Society of Geriatric Emergency & Critical Care Medicine.
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PCI for AMI in the Elderly
Case Presentation
A 96-year-old female patient had no established systemic
diseases. She had suffered from chest tightness extending to the shoulder for 1 hour by the time of arrival at
our emergency department. On arrival, the patient’s
vital signs were as follows: pulse rate 80 beats/minute;
respiratory rate 20 breaths/minute; and blood pressure 145/60 mmHg. Physical examination of the patient
revealed inspiratory crackles of the bilateral lung field.
An electrocardiogram showed ST-segment elevation in
leads V1-4, II, III and aVF (Figure 1). Chest radiography
demonstrated diffuse bilateral lower interstitial infiltration, compatible with pulmonary edema. Blood tests
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showed normal electrolytes; creatinine, 1.1 (0.5–0.9)
mg/dL; creatine kinase, 34 U/L with MB fraction, 22 U/L;
troponin-I, 0.3 (< 0.01) μg/L; low-density lipoprotein
cholesterol 95 mg/dL; and hemoglobin, 11.3 g/dL. The
application of thrombolytic therapy in this patient was
discounted owing to a high bleeding risk. The risk of
bleeding was related to the patient’s old age, female
sex, and very low body weight (27 kg). An emergency PCI
was arranged after obtaining written informed consent.
We performed coronary angiography (CAG) and PCI by
the right femoral approach, using a 6 French guiding
catheter. The CAG revealed total occlusion of the middle
part of the left anterior descending artery (Figure 2A),
patent left circumflex artery, and 80% stenosis of the
Figure 1. Electrocardiogram demonstrating 1-mm to 4-mm ST-segment elevations in leads V1-4, II, III and aVF.
A
B
Figure 2. (A) Coronary angiography revealing total occlusion of the middle part of the left anterior descending artery (black
arrow). (B) Repeat coronary angiography following successful percutaneous coronary intervention of the left anterior
descending artery.
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L.C. Sung, J.H. Wang
middle part of the right coronary artery. The target
vessel revascularization was performed by stenting of
the left anterior descending artery (Figure 2B). The
patient’s chest pain subsided after the PCI procedure.
Transthoracic echocardiography 5 days after AMI showed
mild hypokinesis of the anteroseptal wall of the left
ventricle with an estimated ejection fraction of 53%. The
peak values of creatinine kinase and its MB fraction
were 708 U/L and 167 U/L, respectively. The patient was
discharged 7 days after admission. She had regular outpatient follow-up and received optimal medications,
including aspirin, clopidogrel, lipid-lowering agent,
nicorandil, β-blocker and a renin-angiotensin system
inhibitor. She had no major adverse cardiac events
within 1 year.
Unfortunately, the patient returned to the emergency department with chest tightness and a poor response to sublingual nitroglycerin over 2 days. The
electrocardiogram revealed atrial premature complex
without significant ST-segment deviation (Figure 3).
The troponin-I level was 0.12 μg/L. She was diagnosed
with non-ST segment elevation myocardial infarction
(NSTEMI) and admitted to the intensive care unit. The
transthoracic echocardiography showed mild hypokinesis of the inferior wall of the left ventricle with estimated ejection fraction of 59%. The thrombolysis in
myocardial infarction risk score for NSTEMI in our patient
was 5 points (age > 65 years, coronary stenosis ≥ 50%,
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elevated troponin-I, aspirin use in last 7 days, > 2 angina
events within the previous 24 hours). The patient fell
into a high-risk category and early PCI was indicated.
The family consented to PCI after we discussed the
overall risks and benefits of this procedure. The CAG
revealed 85% stenosis of the middle part of the right
coronary artery (Figure 4A). Direct stenting completely
covering this irregular plaque was performed successfully (Figure 4B). The symptoms of this patient improved
and she was discharged 5 days later. During the 4-month
follow-up period, the patient has remained free of
symptoms without any cardiovascular event.
Discussion
Ischemic heart disease is the leading cause of death
among elderly populations. It was reported that 83% of
those dying from ischemic heart disease were > 65 years
of age2 and that short-term and long-term mortality
after AMI increased with advancing age3. There are very
few reports regarding the results of reperfusion therapy
in nonagenarians (patients aged ≥ 90 years) with AMI.
Reperfusion therapy, including thrombolytic therapy
or PCI, is an effective treatment for patients with STEMI.
Old age is usually a determinant factor for not using
reperfusion therapy. The use of thrombolytic therapy
with no reperfusion in the elderly was compared in
Figure 3. Electrocardiogram demonstrating atrial premature complex without significant ST-segment deviation.
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PCI for AMI in the Elderly
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B
Figure 4. (A) Coronary angiography revealing 85% stenosis of the middle part of the right coronary artery (black arrow).
(B) Repeat coronary angiography following successful stenting of the right coronary artery.
previous registries. Intravenous thrombolysis decreases
mortality among elderly patients4. However, the risk of
intracranial hemorrhage (ICH) increases with age (2.9%
for those > 85 years old)5. ICH is also associated with elevated diastolic pressure (≥ 95 mmHg), female sex, recent
head trauma, diabetes, prior cerebrovascular disease,
low body weight (< 70 kg), and fibrin-specific agents (tissue plasminogen activator, tPA)4. Our patient had three
risk factors for ICH. In the Assessment of the Safety and
efficacy of a New Thrombolytic (ASSENT-2) trial, tenecteplase (TNK-tissue plasminogen activator [TNK-tPA])
was associated with a lower rate of ICH (1.1%) compared
with tPA (3%) in the elderly6. In the ASSENT-3 Plus trial, a
lower rate of ICH was seen with unfractionated heparin
(1.2%) as opposed to enoxaparin (6.7%) when administered with tenecteplase in the elderly7. Tenecteplase
and unfractionated heparin may be suitable for elderly
patients according to the results of ASSENT-2/ASSENT-3
Plus. Our patient arrived at the emergency department
within the first 3 hours after the onset of symptoms, thus
was eligible for both thrombolysis and primary PCI, according to the current American College of CardiologyAmerican Heart Association guidelines8. Although this
patient had no absolute contraindications for the use
of thrombolytic agents, we did not give TNK-tPA as this
patient was at high risk of ICH. Also, the cardiac catheterization services are available 24 hours per day in our
institution. Primary PCI is associated with significant
clinical benefit when compared with thrombolytic
therapy in small randomized trials, meta-analyses and
observational studies9–11. Although a few trials comparing primary PCI with fibrinolytic therapy in older
patients have been reported, more data are needed in
patients ≥ 80 years of age4. The major clinical benefit
International Journal of Gerontology | September 2010 | Vol 4 | No 3
of primary PCI is a reduction in reinfarction and target
vessel revascularization. The reduction in mortality is
less significant. We also assumed that complete revascularization by PCI offered greater benefit in patients
with anteroseptal STEMI.
The independent predictors of mortality after AMI in
nonagenarians in one retrospective analysis included
low body mass index (BMI) (< 25 kg/m2), impaired renal
function (creatinine ≥ 2.0 mg/dL), anemia (hemoglobin
< 11 g/dL), and dementia3. Low body weight is more
prevalent in nonagenarians. A lower BMI may indicate
chronic inflammation, malnutrition, or frailty and correlate with poor outcomes3. Our patient had very low
BMI (11.7 kg/m2) but denied recent body weight loss or
poor food intake. We considered that a stable low body
weight might not be associated with poor prognosis.
Such patients may tolerate further invasive therapy well
if the PCI is performed with a short procedural time,
simple technique, and less contrast media.
Reports on PCI in nonagenarians are very rare1,12–14.
Wu et al.1 reported the results of in-hospital mortality
(0%) and major adverse cardiac events (8%) at 6 months
of follow-up in 12 nonagenarians after PCI were better
than in 6 nonagenarians under medical treatment only.
They also concluded that PCI in the elderly can be performed as effectively and safely as in younger patients1.
Moreno et al.12 reported 26 nonagenarians undergoing
PCI. The PCI achieved a successful angiographic outcome in most patients, but mortality was concentrated
in patients with cardiogenic shock or primary PCI for
STEMI from left anterior descending artery occlusion12.
The factors associated with 6-month mortality were
urgent PCI, diabetes, blood pressure, thrombolysis in
myocardial infarction flow at baseline, left ventricle
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function, renal failure, and procedural success13. PCI
improved quality of life in the elderly, with relief of
angina and increased functional status14.
Our patient developed NSTEMI 18 months after the
first myocardial infarction. We performed a CAG examination for the following reasons: (1) the thrombolysis
in myocardial infarction risk score was high, which
indicated greater benefit of early invasive therapy according to studies of a broad range of patient groups,
including the elderly2; (2) the causes of NSTEMI must
be evaluated for further definitive therapy. If in-stent
restenosis occurs, we could use intravascular ultrasound
to detect its mechanism and use it to guide therapy
such as balloon angioplasty, drug-eluting stent implantation or coronary artery bypass surgery (CABG). There
is a paucity of data among nonagenarians undergoing
PCI with a drug-eluting stent15. The authors15 have reported that PCI with such a stent was safe without inhospital deaths and an acceptable 3-year survival rate
(61% ± 9%). However, because of unpredictable compliance to long-term dual antiplatelet therapy in elderly
patients, caution should be exercised in the extensive
use of the drug-eluting stent. If there is no ISR, it means
the result of stent implantation is good and further PCI
with a stent is feasible. Our patient underwent a CAG
that revealed no in-stent restenosis within the left anterior descending artery 18 months later. We assumed that
a restenosis was less likely after another PCI. Although
an early invasive strategy for elderly patients with
NSTEMI demonstrates greater benefits in reducing death
and recurrent myocardial infarction, there is little evidence to guide management in nonagenarians2. The elderly populations have more comorbidities, so secondary
causes of NSTEMI such as anemia, tachycardia, or sepsis
must be considered. Also, functional status, frailty, social
aspects of care, bleeding risk with antithrombotic therapies, and contrast medium-induced acute renal failure should be always taken into consideration. Careful
patient selection and full assessment of the risk-tobenefit ratio is important for the physician to make treatment decisions. It is also mandatory to perform close
postprocedural monitoring of the patient’s condition.
The European System for Cardiac Operative Risk
Evaluation (EuroSCORE) is a scoring system for predicting
operative mortality before CABG16. The EuroSCORE of
our patient was 13 points, which indicated predicted
operative mortality of about 35%. The paucity of information about the clinical outcomes for nonagenarians
provides little guidance to physicians about the risks
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and benefits of undergoing a CABG procedure. Bridges
et al.17 reported operative mortality of 11.8% for 663
nonagenarians undergoing CABG. The major predictors of operative mortality in this age group were
emergency/salvage CABG, renal failure, preoperative
intra-aortic balloon pump, peripheral vascular disease, the presence of mitral regurgitation, and cerebrovascular disease. Lichtman et al.18 retrospectively
analyzed 4,224 nonagenarians (2,068 women, 2,156
men) from the Medicare Enrollment Database who
underwent CABG from 1993 to 1999. The mortality
after CABG was 13.5% at 1 month, and 26.6% and
59.0% after 1 and 5 years of follow-up, respectively.
They also found that short-term mortality trends were
comparative for men and women, but men tended
toward a higher mortality rate in the 2-year to 5-year
results. They had a life expectancy similar to that of
their elderly peers.
From this case we learn that primary PCI is always
necessary and has an acceptable result in nonagenarians with STEMI, especially of the anteroseptal wall.
Thrombolysis is an alternative therapy within 3 hours
of symptom onset, but it has a potential risk of ICH. In
nonagenarians with NSTEMI, a secondary cause is more
frequent and should be carefully excluded. The selection of CABG, PCI with a bare-metal stent/DES, thrombolytics, or no reperfusion therapy depend on the
characteristics of the lesions, coronary artery involvement, the patient’s underlying illness, the patient’s
and family’s wishes, and quality-of-life outcomes.
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