Abciximab in elderly with Acute Coronary Syndrome invasively treated: Effect on outcome

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Abstract

Older age is an independent predictor of mortality after percutaneous coronary intervention (PCI) in patients with Non-ST elevation Acute Coronary Syndrome (ACS). GPIIb/IIIa inhibitors are proved to improve outcome in high risk patients, but conflicting data are available about the effects of these inhibitors in elderly. Accordingly, we studied a consecutive population of elderly patients undergoing PCI for Non-ST elevation ACS. A total of 500 patients were divided in: GPI group (247 pts; mean age 77 ± 1.9 years) treated by stenting plus abciximab and, no GPI group (253 pts; mean age 77 ± 2.4 years) treated by stenting alone. Propensity analysis was used to account for the nonrandomized use of GPIIb/IIIa inhibitors. During hospitalization, incidence of death was similar among groups (3.2% vs 4.6%) without difference regarding incidence of major (1.6% vs 1.1%) and minor bleedings (4% vs 3%). At long-term follow-up the rate of death was significantly lower in GPI group (4.5% vs 12.3%; p = 0.002) as well as the rate of acute myocardial infarction (2.8% vs 11.1%; p = 0.0001), and pre-PCI (5.7% vs 13.4%; p = 0.003). Cox regression analysis identified abciximab use as an independent predictor of lower long-term major adverse cardiac event (MACE) after adjustment for propensity score (Exp (B) 0.620, 95%CI 0.394–0.976, p = 0.039). Our results suggest that addition of abciximab to stenting improves outcome in elderly patients with Non-ST elevation ACS, leading to an absolute benefit for reduction of death and MACE, with an acceptable rate of major and minor bleedings.

Introduction

Elderly are increasingly represented among patients with Acute Coronary Syndromes (ACS), and advanced age has been identified as an important risk factor for death and adverse outcome in patients with ACS invasively treated [1]. Although several data have demonstrated the prognostic benefit of early revascularization in ACS particularly in high risk patients, [2], [3], [4] elderly with ACS are less treated with invasive procedures than younger patients [5], [6]. Besides, tough intravenous administration of platelet glycoprotein (GP) IIb/IIIa receptor antagonists has been showed effective in reducing ischemic complications in patients presenting with ACS and also during percutaneous coronary intervention (PCI) [2], [6], elderly patients are less often treated with these agents [7], [8], [9]. Moreover administrations of GPIIb/IIIa inhibitors (GPI) in these patients are still controversial since elderly have traditionally been underrepresented in clinical trial of ACS [10]. Consistently with lack of available study and current uncertainties regarding use of GPIIb/IIIa inhibitors in elderly, we analyzed clinical outcome in a consecutive series of elderly patients with Non-ST-elevation ACS who underwent coronary stenting with or without use of the GPIIb/IIIa receptor antagonists abciximab.

Section snippets

Study population

All patients aged ≥ 75 years with Non-ST-ACS [11] undergoing PCI at Federico II University of Naples from January 2001 to December 2003 were included in the study and stratified according to the use of abciximab, a potent GPIIb/IIIa inhibitor [12], [13], [14], [15].

PCI procedure, clinical and angiographic data analysis

PCI was performed according to the AHA/ACC guidelines, [16] through femoral approach using small size arterial sheaths (6F). Informed consent was obtained from each patient (or from their relatives in case of patient's inability)

Baseline characteristics

Between January 2001 and December 2003, 540 patients aged ≥ 75 years underwent PCI at Federico II University for Non-ST-ACS. Of these 247 patients (46%) received abciximab at the operator's discretion. Thus, according with GPIIb/IIIa inhibitor administration, we divided the study population into: GPI group (247 pts; mean age 77 ± 1.9 years; 71.8% male) treated by stenting plus abciximab and, no GPI (253 pts; mean age 77 ± 2.4 years; 76.9% male) treated by stenting alone. Baseline clinical

Discussion

Our results suggest that association of abciximab to stenting in elderly patients with Non-ST elevation ACS improves outcome by reducing MACE with a slight increase of bleedings.

Advanced age has been associated with an adverse outcome after an episode of Non-ST-elevation Acute Coronary Syndrome [1], [23], [24] and elderly patients represent a high risk population for coronary revascularization, being advanced age an independent predictor of overall mortality often associated with more diffuse

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