title: Treatment choices in elderly patients with ST: elevation myocardial infarction-insights from the Vital Heart Response registry.
abstract: Management of elderly patients with ST elevation myocardial infarction (STEMI) is challenging and they are under-represented in trials. Accordingly, we analysed reperfusion strategies and their effectiveness in patients with STEMI ≥75 years compared to <75 years within a comprehensive inclusive registry.
  
  
  
  Consecutive patients with STEMI admitted to hospital and tracked within a regional registry (2006-2011) were analysed comparing reperfusion strategy (primary percutaneous coronary intervention (PPCI), fibrinolysis and no reperfusion) between patients ≥75 vs <75 years old as well as across the reperfusion strategies in those ≥75 years.
  
  
  
  There were 3588 patients with STEMI with 646 (18%) ≥75 years old. Elderly patients were more likely female (46.9% vs 18.4%) and had more prior: angina (28.2% vs 17.2%), myocardial infarction (MI; 22.8% vs 13.9%), hypertension (67.6% vs 44.2%), heart failure (2.3% vs 0.3%) and atrial fibrillation (2.2% vs 0.5%) (all p<0.001). The reperfusion strategy for patients ≥75 vs <75: PPCI 45.3% vs 41.2%, fibrinolysis 24.8% vs 45.7%, and no reperfusion 29.9% vs 13.1% (p<0.001). Time from symptoms to first medical contact (median, 93 vs 78 min p=0.008) and PPCI (median, 166 vs 136 min (p<0.001) were longer for ≥75 years. In those ≥75 years outcomes by reperfusion (PPCI, fibrinolysis and none) were: in-hospital death 13.3%, 9.4% and 19.7% (p=0.018), and composite of death, recurrent-MI, cardiogenic shock and congestive heart failure 28%, 20% and 33.2% (p=0.022).
  
  
  
  Elderly patients have more comorbidities, worst in-hospital clinical outcomes and are less likely to receive reperfusion. Acknowledging physician selection of the reperfusion strategy; outcomes appear favourable in the elderly receiving fibrinolysis.
authors.affiliation: University of Alberta , Edmonton, Alberta , Canada.
authors.forename: Olga
authors.initials: O
authors.lastname: Toleva
authors.affiliation: University of Alberta , Edmonton, Alberta , Canada.
authors.forename: Quazi
authors.initials: Q
authors.lastname: Ibrahim
authors.affiliation: Royal Alexandra Hospital and CK Hui Heart Centre , Edmonton, Alberta , Canada.
authors.forename: Neil
authors.initials: N
authors.lastname: Brass
authors.affiliation: University of Alberta , Edmonton, Alberta , Canada.
authors.forename: Sunil
authors.initials: S
authors.lastname: Sookram
authors.affiliation: University of Alberta , Edmonton, Alberta , Canada ; Mazankowski Alberta Heart Institute, Edmonton, Alberta , Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Welsh