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Vol. 72. Issue 3.
Pages 263-266 (March 2019)
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Vol. 72. Issue 3.
Pages 263-266 (March 2019)
Scientific letter
DOI: 10.1016/j.rec.2018.01.020
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Clinical Characteristics and Prognosis of Very Elderly Patients With Acute Coronary Syndrome Treated With Ticagrelor: Insights From the LONGEVO-SCA Registry
Perfil clínico y pronóstico del paciente muy anciano con síndrome coronario agudo tratado con ticagrelor. Datos del registro LONGEVO-SCA
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Albert Ariza-Soléa,
Corresponding author
aariza@bellvitgehospital.cat

Corresponding author:
, Francesc Formigab, Alfredo Bardajíc, Ana Viana-Tejedord, Oriol Alegrea, Fernando de Frutosa
a Servicio de Cardiología, Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
b Unidad de Geriatría, Servicio de Medicina Interna, Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
c Servicio de Cardiología, Hospital Joan XXIII, Tarragona, Spain
d Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain
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Table. Baseline Characteristics, Treatment and Prognosis According to Ticagrelor Prescription at Discharge
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To the Editor,

Clinical practice guidelines recommend ticagrelor or prasugrel as first line drugs in non–ST-elevation acute coronary syndrome (NSTEMI), and clopidogrel has been relegated to patients with contraindications to these drugs (especially high risk of bleeding).1 Elderly patients are under-represented in the clinical trials that support these recommendations. Possibly because of that, underuse of these drugs in everyday clinical practice has been described, especially in elderly patients with comorbidities.2–4 There is very little information on antiplatelet treatment and its impact on geriatric assessment in elderly patients with NSTEMI.

The LONGEVO-SCA registry included patients aged ≥ 80 years with NSTEMI from 44 Spanish hospitals, where the patients underwent an in-hospital geriatric assessment and their 6-month prognosis was analyzed.5 The primary endpoint of the study was total mortality and its causes at 6 months; secondary endpoints were the readmission, bleeding, and reinfarction rates and new revascularization procedures.

The aim of this analysis was to describe the clinical profile and outcomes in patients who survived to hospital admission, according to whether or not they were prescribed ticagrelor on discharge, excluding patients treated with oral anticoagulants (n = 86). The analysis included total mortality, readmissions, bleeding (BARC 2, 3, or 5) and ischemic events (cardiac mortality, reinfarction, or new revascularization procedures) at 6 months. Cox regression was used for the adjusted analysis, with the variables that showed an association (P < 0.1) with either exposure (ticagrelor) or effect: admitting unit, age, previous heart failure, atrial fibrillation, Killip class, hemoglobin, creatinine clearance, invasive management, left main trunk stenosis, revascularization during admission, GRACE, CRUSADE and PRECISE-DAPT scores, and Lawton-Brody, Charlson, nutritional risk, and frailty indexes.

The analysis included 413 patients, 63 of whom (15.2%) received ticagrelor on discharge. These patients were admitted more often to critical care units, were younger, and more often male (Table 1). They had a higher prevalence of atrial fibrillation and bleeding prior to admission. Furthermore, they had slightly lower GRACE scores, with a lower bleeding risk profile. They underwent coronary angiography more often and had a higher percentage of left main trunk stenosis and a higher frequency of percutaneous revascularization.

Table.

Baseline Characteristics, Treatment and Prognosis According to Ticagrelor Prescription at Discharge

  Ticagrelor at discharge (n = 63)  No ticagrelor at discharge (n = 350)  P 
Admitting unit.011 
Intensive care  9 (14.3)  20 (5.7)   
Coronary care unit  17 (27)  73 (20.9)   
Cardiology ward  33 (52.4)  221 (63.1)   
Internal medicine  22 (6.3)   
Elderly care  5 (1.4)   
Other  4 (6.3)  9 (2.6)   
Age. y  82.7 ± 2.6  84.8 ± 4  .001 
Male  49 (77.8)  206 (58.9)  .006 
Body mass index  27.5 ± 4  26.6 ± 4  .084 
Hypertension  53 (84.1)  297 (84.8)  .642 
Diabetes mellitus  27 (42.9)  133 (38)  .531 
Previous stroke  6 (9.5)  51 (14.3)  .515 
Peripheral vascular disease  6 (9.5)  50 (14.3)  .288 
Previous myocardial infarction  18 (28.6)  127 (36.3)  .203 
Previous heart failure  4 (6.3)  57 (16.3)  .037 
Previous atrial fibrillation  1 (1.6)  31 (8.9)  .027 
Previous bleeding  1 (1.6)  23 (6.6)  .089 
Previous neoplasm  9 (14.3)  58 (16.6)  .612 
Killip class ≥ II on admission  12 (19.0)  126 (28.9)  .078 
Baseline hemoglobin, g/dL  13.1 ± 2  12.6 ± 2  .081 
Creatinine clearance  53 ± 20)  48 ± 20  .042 
LVEF, %  56 ± 11  53 ± 12  .191 
Invasive management  59 (93.7)  258 (73.7)  .001 
Left main trunk stenosis  17 (28.8)  38 (14.7)  .001 
Multivessel disease  38 (64.4)  137 (53.1)  .053 
Revascularization.001 
No  8 (12.7)  177 (50.6)   
PCI  54 (85.7)  167 (47.7)   
Coronary surgery  1 (1.6)  6 (1.7)   
GRACE score  159 ± 22  166 ± 29  .090 
CRUSADE score  36 ± 11  42 ± 13  .001 
PRECISE-DAPT score  32.9 ± 10  39 ± 12  .001 
Geriatric syndromes
Disability (Barthel index).135 
Independent  49 (77.8)  217 (62)   
Mild dependency  12 (19)  94 (26.9)   
Moderate dependency  1 (1.6)  19 (5.4)   
Severe dependency  1 (1.6)  11 (3.1)   
Completely dependent  9 (2.6)   
Instrumental activities (Lawton-Brody index)  6.3 ± 2  5.3 ± 3  .001 
Comorbidity (Charlson index)  2 ± 1.7  2.5 ± 1.9  .040 
Cognitive impairment (Pfeiffer test).149 
None  49 (77.8)  227 (64.9)   
Moderate  13 (20.6)  112 (32)   
Severe  1 (1.6)  9 (2.6)   
Nutritional risk (MNA-SF)  24 (38.7)  189 (54)  .020 
Frailty (FRAIL scale).007 
No  29 (46)  110 (31.4)   
Pre-frail  27 (42.9)  140 (40)   
Frail  7 (11.1)  100 (22.6)   
Events at 6 months
Bleeding  2 (3.2)  19 (5.4)  .420 
Readmission due to bleeding  14 (4)  .087 
Required transfusion  9 (2.5)  .211 
Intervention due to bleeding  1 (1.6)  3 (0.9)  .496 
Change in antiplatelet agent  1 (1.6)  13 (3.7)  .326 
Fatal bleeding  1 (0.3)  .843 
Cardiac death, reinfarction, or new revascularization  5 (7.9)  61 (17.4)  .057 
Cardiac death  2 (3.2)  26 (7.4)  .168 
Reinfarction  4 (6.3)  37 (10.6)  .299 
New revascularization  1 (1.6)  20 (5.7)  .138 
Total mortality  2 (3.2)  44 (12.6)  .029 
Readmission  10 (15.9)  131 (30)  .018 
Death or readmission  11 (17.5)  127 (36.3)  .004 

LVEF, left ventricular ejection fraction; MNA-SF, Mini nutritional asssessment-Short Form; PCI, percutaneous coronary intervention.

Values are expressed as No. (%) or mean ± standard deviation.

The patients in the ticagrelor group had a greater capacity for instrumental activities, lower degrees of comorbidity, and a lower prevalence of frailty and nutritional risk.

The incidence of bleeding was low in both groups, with no significant differences (3.2% vs 5.4%). The patients in the ticagrelor group had a slightly lower incidence of ischemic events and a lower incidence of death or readmission (Figure 1). After adjustment for confounding factors, the effect of treatment with ticagrelor was clearly not significant for either ischemic events (hazard ratio [HR] = 0.81; 95% confidence interval [95%CI], 0.33-4.21; P = .807) or mortality or readmission (HR = 0.79; 95%CI, 0.37-1.73; P = .565).

Figure.

Cumulative survival free from bleeding events (A), ischemic events (B) and death or readmission (C), according to ticagrelor prescription at discharge.

(0.16MB).

The findings of this study are in line with those of previous publications and show the low rate of ticagrelor use in elderly patients in our setting,2 which is inversely proportional to the ischemic and bleeding risk.3,4

Some factors limit the robustness of these findings. This was an observational registry, with probable selection bias and unmeasured confounding factors. The small size of the ticagrelor group made it difficult to study the impact of treatment on outcomes. Finally, a longer follow-up would have allowed us to optimize the study of mid-term outcomes, although it is known that the highest risk of bleeding is concentrated in the first months after an event.

Nonetheless, in light of these results, it seems justified to assert that, although the adjusted analysis did not show a clinical benefit, ticagrelor is reasonably safe for selected patients ≥ 80 years, despite their theoretical bleeding risk profile (more than 85% of the ticagrelor group had a PRECISE-DAPT score ≥ 25, considered high bleeding risk in the recent guidelines1). This patient profile has scarcely been studied yet continues to grow in our everyday clinical practice.

FUNDING

The LONGEVO-SCA registry has received funding from the Spanish Society of Cardiology.

CONFLICTS OF INTEREST

A. Ariza-Solé has received conference fees from AstraZeneca.

.

Acknowledgements

The LONGEVO-SCA registry investigators.

References
[1]
M. Valgimigli, H. Bueno, R.A. Byrne, 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS, et al.
The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS).
[2]
M.A. Esteve-Pastor, J.M. Ruíz-Nodar, E. Orenes-Piñero, et al.
Temporal trends in the use of antiplatelet therapy in patients with acute coronary syndromes.
J Cardiovasc Pharmacol Ther., 23 (2018), pp. 57-65
[3]
P.J. Flores-Blanco, F. Cambronero-Sánchez, S. Raposeiras-Roubin, et al.
Association Between Ischemic and Bleeding Risk Scores and the use of new P2Y12 Inhibitors in Patients With Acute Coronary Syndrome.
[4]
M. Almendro-Delia, Á. García-Alcántara, M.V. De la Torre-Prados, et al.
Safety and Efficacy of Prasugrel and Ticagrelor in Acute Coronary Syndrome. Results of a “Real World” Multicenter Registry.
Rev Esp Cardiol., 70 (2017), pp. 952-959
[5]
O. Alegre, A. Ariza-Solé, M.T. Vidán, et al.
Impact of frailty and other geriatric syndromes on clinical management and outcomes in elderly patients with non-ST-segment elevation acute coronary syndromes: rationale and design of the LONGEVO-SCA Registry.
Clin Cardiol., 39 (2016), pp. 373-377
Copyright © 2018. Sociedad Española de Cardiología
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