Seksen yaş altı ve üstü hastalarda ST yükselmeli miyokart enfarktüsü için başarılı birincil anjiyoplasti sonrası erken ve geç dönem klinik sonuçların karşılaştırılması

Dr. Vecih Oduncu, Dr. Ayhan Erkol, Dr. Ali Cevat Tanalp, Dr. Cevat Kırma, Dr. Mustafa Bulut, Dr. Atila Bitigen, Dr. Selçuk Pala, Dr. Kürşat Tigen, Dr. Ali M. Esen

Department of Cardiology, Medical Park Fatih Hospital, İstanbul

Department of Cardiology, Kocaeli Derince Training and Research Hospital, Kocaeli

Department of Cardiology, Medicana International Hospital, Ankara

Department of Cardiology, Kartal Koşuyolu Heart Training and Research Hospital, İstanbul

Department of Cardiology, Marmara University Faculty of Medicine, Istanbul

- İbni Sina Bulvarı, Derince, 41900 Kocaeli, Turkey. Tel: +90 262 - 317 80 01 e-mail: ayhanerkol@yahoo.com

Teslim Tarihi: 30 Temmuz 2012

Kabul Tarihi: 08 Şubat 2013

TKD Arşivi 2013, Cilt 41, Sayı 4, Page 319-328, DOI: 10.5543/tkda.2013.76059

Amaç: Birincil (primer) perkütan koroner girişimin (p-PKG), ≥80 yaş ve <80 yaş ST yükselmeli miyokart enfarktüslü (STYME) hastalarda etkinliğini karşılaştırmayı amaçladık.

Çalışma planı: Akut STYME nedeniyle p-PKG uygulanan 2213 hasta geriye dönük olarak çalışmaya alındı. Hastalar ileriye dönük olarak (median süre 42 ay) takip edildi. Erken ve geç dönem klinik sonlanımlar yaşa göre karşılaştırıldı. 

Bulgular: Hastaların 179’u 80 yaş ve üzerinde idi. İşlem sonrası TIMI 3 akım 80 yaş ve üzeri hastalarda anlamlı olarak daha nadirdi (%82.1 ve %91.1, p<0.001). Hastane içi erken dönemde mortalite (%14.5 ve %3.4, p<0.001), kalp yetersizliği (%20.7 ve %10.5, p<0.001), majör kanama (%9.5 ve %3.3, p<0.001), ikincil VT/VF (%10.1 ve %4.2, p=0.002) ve atriyum fibrilasyonu (%12.8 ve %4.3, p<0.001) oranları, 80 yaş ve üzeri grubu hastalarda anlamlı olarak daha yüksek idi. Toplam mortalite (%40 ve %9.7, p<0.001) ve inme (%5.6 ve %1.1, p=0.005) oranları uzun dönem takipte 80 yaş ve üzeri grubu hastalarda daha yüksek idi. Ancak, iki grup arasında tekrarlayan enfarktüs/revaskülarizasyon oranları açısından fark yoktu. Cox orantısal risk modeli ile yapılan analiz, 80 ve üzeri yaşın uzun dönem mortalite için bağımsız öngördürücü olduğunu gösterdi (risk oranı 2.17, %95 güven aralığı 1.23-4.17, p=0.02).

Sonuç: Yaş, STYME nedeniyle p-PKG yapılan hastalarda mortalitenin bağımsız öngördürücüsüdür. Erken dönem klinik sonuçları olumlu gözükse de, p-PKG’nin uzun dönem klinik etkinliği çok yaşlı hastalarda kısıtlı gözükmektedir.

As a result of increased life expectancy, elderly individuals constitute an increasing proportion of patients admitted to hospitals for acute ST elevation myocardial infarction (STEMI). The selection of reperfusion strategy for elderly patients with acute STEMI bears great importance due to the high complication and low efficacy rates of fibrinolytic (FL) therapy.[1,2] Currently, primary percutaneous coronary intervention (p-PCI) is the most commonly preferred reperfusion strategy. Compared with FL therapy, mortality rates are significantly lower. However, there is still controversy regarding the efficacy of p-PCI in patients of advanced age due to limited outcome data in the literature.[2]

We aimed to compare the efficacy of primary percutaneous coronary intervention (p-PCI) in patients ≥80 versus <80 years of age with ST-segment elevation myocardial infarction (STEMI).

1. Franzosi MG, Santoro E, De Vita C, Geraci E, Lotto A, Maggioni AP, et al. Ten-year follow-up of the first megatrial testing thrombolytic therapy in patients with acute myocardial infarction: results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto-1 study. The GISSI Investigators. Circulation 1998;98:2659-65.

2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13-20.  

3. World Health Organization. Nutritional anemias: report of a WHO scientific group. Geneva: World Health Organization; 1968. 

4. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461-70.  

5. Rentrop KP, Cohen M, Blanke H, Phillips RA. Changes in collateral channel filling immediately after controlled coronary artery occlusion by an angioplasty balloon in human subjects. J Am Coll Cardiol 1985;5:587-92.  

6. de Lemos JA, Braunwald E. ST segment resolution as a tool for assessing the efficacy of reperfusion therapy. J Am Coll Cardiol 2001;38:1283-94.  

7. Rao AK, Pratt C, Berke A, Jaffe A, Ockene I, Schreiber TL, et al. Thrombolysis in Myocardial Infarction (TIMI) Trial- -phase I: hemorrhagic manifestations and changes in plasma fibrinogen and the fibrinolytic system in patients treated with recombinant tissue plasminogen activator and streptokinase. J Am Coll Cardiol 1988;11:1-11.  

8. Grines C. Senior PAMI. A prospective randomized trial of primary angioplasty and thrombolytic therapy in elderly patients with acute myocardial infarction. Presented at Transcatheter Therapeutics (TCT); October 2005, Washington, DC. 

9. White HD, Barbash GI, Califf RM, Simes RJ, Granger CB, Weaver WD, et al. Age and outcome with contemporary thrombolytic therapy. Results from the GUSTO-I trial. Global Utilization of Streptokinase and TPA for Occluded coronary arteries trial. Circulation 1996;94:1826-33.  

10. de Boer SP, Westerhout CM, Simes RJ, Granger CB, Zijlstra F, Boersma E; Primary Coronary Angioplasty Versus Thrombolysis- 2 (PCAT-2) Trialists Collaborators Group. Mortality and morbidity reduction by primary percutaneous coronary intervention is independent of the patient’s age. JACC Cardiovasc Interv 2010;3:324-31.  

11. Fosbøl EL, Thune JJ, Kelbaek H, Andersen HR, Saunamäki K, Nielsen TT, et al. Long-term outcome of primary angioplasty compared with fibrinolysis across age groups: a Danish Multicenter Randomized Study on Fibrinolytic Therapy Versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI-2) substudy. Am Heart J 2008;156:391-6. 

12. Singh M, Mathew V, Garratt KN, Berger PB, Grill DE, Bell MR, et al. Effect of age on the outcome of angioplasty for acute myocardial infarction among patients treated at the Mayo Clinic. Am J Med 2000;108:187-92.  

13. Bueno H, Betriu A, Heras M, Alonso JJ, Cequier A, García EJ, et al. Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J 2011;32:51-60.

14. Ottani F, Galvani M, Ferrini D, Sorbello F, Limonetti P, Pantoli D, et al. Prodromal angina limits infarct size. A role for ischemic preconditioning. Circulation 1995;91:291-7.  

15. Anzai T, Yoshikawa T, Asakura Y, Abe S, Akaishi M, Mitamura H, et al. Preinfarction angina as a major predictor of left ventricular function and long-term prognosis after a first Q wave myocardial infarction. J Am Coll Cardiol 1995;26:319- 27.  

16. Abete P, Ferrara N, Cacciatore F, Madrid A, Bianco S, Calabrese C, et al. Angina-induced protection against myocardial infarction in adult and elderly patients: a loss of preconditioning mechanism in the aging heart? J Am Coll Cardiol 1997;30:947-54.  

17. Rittger H, Rieber J, Breithardt OA, Dücker M, Schmidt M, Abbara S, et al. Influence of age on pain perception in acute myocardial ischemia: a possible cause for delayed treatment in elderly patients. Int J Cardiol 2011;149:63-7.  

18. Kurotobi T, Sato H, Kinjo K, Nakatani D, Mizuno H, Shimizu M, et al. Reduced collateral circulation to the infarct-related artery in elderly patients with acute myocardial infarction. J Am Coll Cardiol 2004;44:28-34.  

19. Keeley EC, Hillis LD. Primary PCI for myocardial infarction with ST-segment elevation. N Engl J Med 2007;356:47-54. 

20. Spencer FA, Moscucci M, Granger CB, Gore JM, Goldberg RJ, Steg PG, et al. Does comorbidity account for the excess mortality in patients with major bleeding in acute myocardial infarction? Circulation 2007;116:2793-801.  

21. Rao SV, Jollis JG, Harrington RA, Granger CB, Newby LK, Armstrong PW, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA 2004;292:1555-62.

© 2015 Türk Kardiyoloji Derneği. Tüm hakları saklıdır. Bu sitedeki içerikler sağlık profesyonelleri için hazırlanmıştır.