Original Investigation
Temporal Trends in Mechanical Complications of Acute Myocardial Infarction in the Elderly

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Abstract

Background

Reperfusion therapy led to an important decline in mortality after ST-segment elevation myocardial infarction (STEMI). Because the rate of cardiogenic shock has not changed dramatically, the authors speculated that a reduction in the incidence or fatality rate of mechanical complications (MCs), the second cause of death in these patients, could explain this decrease.

Objectives

This study sought to assess time trends in the incidence, management, and fatality rates of MC, and its influence on short-term mortality in old patients with STEMI.

Methods

Trends in the incidence and outcomes of MC between 1988 and 2008 were analyzed by Mantel-Haenszel linear association test in 1,393 consecutive patients ≥75 years of age with first STEMI.

Results

Overall in-hospital mortality decreased from 34.3% to 13.4% (relative risk reduction, 61%; p < 0.001). Although the absolute mortality due to MC decreased from 9.6% to 3.3% (p < 0.001), the proportion of deaths due to MC among all deaths did not change (28.1% to 24.5%; p = 0.53). The incidence of MC decreased from 11.1% to 4.3% (relative risk reduction 61%) with no change in their hospital fatality rate over time (from 87.1% to 82.4%; p = 0.66). The proportion of patients undergoing surgical repair decreased from 45.2% to 17.6% (p = 0.04), with no differences in post-operative survival (from 28.6% to 33.3%; p = 0.74).

Conclusions

Although the incidence of MC has decreased substantially since the initiation of reperfusion therapy in elderly STEMI patients, this reduction was proportional to other causes of death and was not accompanied by an improvement in fatality rates, with or without surgery. MCs are less frequent but remain catastrophic complications of STEMI in these patients.

Key Words

cardiac rupture
elderly
mechanical complications
mortality
myocardial infarction
reperfusion
time trends

Abbreviations and Acronyms

AMI
acute myocardial infarction
CVD
cardiovascular disease
FWR
free-wall rupture
MC
mechanical complication
PMR
papillary muscle rupture
PPCI
primary percutaneous coronary intervention
STEMI
ST-segment elevation myocardial infarction
VSR
ventricular septal rupture

Cited by (0)

Dr. Bueno has received research funding from the Instituto de Salud Carlos III (PIE16/00021, PI17/01799), AstraZeneca, Bristol-Myers Squibb, Janssen, and Novartis; consulting fees from AstraZeneca, Bayer, Bristol-Myers Squibb-Pfizer, and Novartis; and speaking fees or support for attending scientific meetings from AstraZeneca, Bayer, Bristol-Myers Squibb-Pfizer, Ferrer, Novartis, and Medscape/the heart.org. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Listen to this manuscript's audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.

Drs. Viana-Tejedor and Bueno were affiliated with the Cardiology Department, Hospital General Universitario Gregorio Marañón, when the registry was done.