1. POSTER :24 – 7:31
Impact of an Invasive Strategy on In-Hospital Outcomes in Nonagenarians with Acute Coronary Syndrome: Insights from the AMI-OPTIMA Study 
Presenter: Etienne L. Couture
Authors: Etienne L. Couture M, Paul Farand MD MSc, Michel Nguyen MD, Catherine Allard MSC, Jonathan Afilalo MD MSC, Marc Afilalo MD, Erick Schampaert MD Mark Eisenberg MD MPH, Martine Montigny MD MSC, Samer Mansour MD, Simon Kouz MD MSC, Jean- Claude Tardif MD, Thao Huynh MD, MSC, PHD

2. The Impact of an Invasive Strategy on In-Hospital Outcomes in Nonagenarians with Acute Coronary Syndrome: Insights from the AMI-OPTIMA Study.
Fellows Poster Competition
Montreal Live Symposium 2016
Etienne Couture, Paul Farand, Michel Nguyen, Catherine Allard, Jonathan Afilalo, Marc Afilalo, Erick Schampaert, Mark Eisenberg, Martine Montigny, Samer Mansour, Simon Kouz, Jean-Claude Tardif, Claude Lauzon, Thao Huynh Thanh.

3. Research Question
Does the invasive strategy is worthwhile in nonagenarians ACS patients in regards to the risks and benefits ?

4. Introduction ACC/AHA Guidelines (Acute coronary care in the elderly)
- ‘’…Very elderly have reasonable outcomes following revascularization in ACS”
Meta-Analysis FRISC II / ICTUS / RITA-3 (routine vs selective invasive)
- 5-years composite in > 75 yo : HR 0.71, 95% CI 0.55 to 0.91
After Eighty-Study (Lancet 2016)
- RCT 457 > 80 yo NSTEACS patients; invasive vs conservative; mean fu 1.5 y
- Primary composite endpoint HR 0.52 (p<0.001)
- Mortality HR 0.89 (p<0.53)
- Nonagenarians (N = 34) HR 1.21 (p=0.64)
Alexander KP Circulation 2007; 115: 2549–69.
Tegn N et al. Lancet 2016; 387: 1057–65
Damman P et al. Heart 2012; 98: 207–13.

5. Methods AMI-OPTIMA Study Ethical Approval Statistical Analysis
- Cluster Randomized study: 100 consecutive ACS in 24 hospitals in Québec (2009 & 12)
- Initial aim: knowledge translation on optimal discharge medication
Ethical Approval
- McGill Universitary Center (coordinating hospital)
Statistical Analysis
- Four age groups stratification (<70, 70-79, 80-89, >=90)
- Multivariate logistic regression to identify predictors of invasive strategy
- Inverse probability weighted analysis

6. Baseline Characteristics and Clinical Presentation
Age, years
Number of patients
Proportion of total AMI-OPTIMA patients
<70
N=2,394
52%
70-79
N=1,031
23%
80-89
N=941
21%
90
N=202
4.4%
P Value
For Trend
Baseline Characteristics
Median Age, years (Q1:Q3)
58 (62-64)
75 (72-77)
84 (82-87)
93 (91-95)
<0.001
Female, %
576 (24)
377 (37)
454 (48)
145 (72)
Hypertension, %
1250 (52)
749 (73)
738 (78)
157 (78)
Diabetes Mellitus, %
590 (25)
357 (35)
312 (33)
45 (22)
Dyslipidemia, %
1291 (54)
644 (63)
536 (57)
74 (37)
0.45
Current Smoker, %
983 (41)
157 (15)
47 (5.0)
1 (0.5)
Obesity (BMI>30), %
686 (29)
193 (19)
109 (12)
9 (4.5)
Peripheral Vascular Artery Disease, %
150 (6.3)
137 (13)
106 (11)
15 (7.4)
Chronic Kidney Disease, %
170 (7.1)
217 (21)
285 (30)
64 (32)
Prior PCI, %
502 (21)
263 (26)
200 (21)
19 (9.4)
0.14
Prior CABG, %
121 (5.1)
117 (11)
124 (13)
14 (6.9)
Clinical Presentation
STEMI, %
849 (36)
234 (23)
161 (17)
38 (19)
NSTEMI, %
859 (36)
455 (44)
492 (52)
114 (56)
Unstable Angina, %
501 (21)
235 (23)
11 (5.4)
Non-specified ACS, %
123 (5.1)
77 (7.5)
85 (9.0)
34 (17)

7. In-hospital medical and invasive therapies
Age, years
<70
N=2,394
70-79
N=1,031
80-89
N=941
90
N=202
P Value
For Trend
 Medications
Fibrinolysis, %
74 (3.1)
15 (1.5)
9 (1.0)
0 (0)
<0.001
DAPT, %
2,040 (85)
770 (75)
621 (66)
89 (44)
Intravenous unfractionated heparin, %
1,995 (83)
804 (78)
608 (65)
109 (54)
LMWH, %
711 (30)
332 (32)
328 (35)
68 (34)
0.004
Fondaparinux, %
15 (0.6)
11 (1.1)
14 (1.5)
0.160
Bivalirudin, %
174 (7.3)
58 (5.6)
43 (4.6)
Gp2b3a inhibitors, %
620 (26)
169 (16)
47 (5)
Invasive Procedures
Cardiac catheterization, %
2,210 (92)
856 (83)
505 (54)
40 (20)
PCI, % of patients who underwent angiogram
Stent, % of patients who underwent PCI
1674 (76)
538 (62)
353 (70)
29 (73)
Bare metal stent, %
972 (58)
293 (54)
226 (64)
22 (76)
Drug-eluting stent, %
545 (33)
191 (36)
92 (26)
4 (14)
0.07
Both types of stents, %
65 (3.9)
13 (2.4)
6 (1.7)
1 (3.4)
0.03
No stent, %
26 (1.6)
9 (1.7)
5 (1.4)
0 (0)
0.81
Staged PCI, %
147 (6.1)
55 (5.3)
40 (4.2)
1 (0.5)
IABP, %
106 (4.4)
50 (4.8)
23 (2.4)
3 (1.5)
In-Hospital CABG, %
223 (9.3)
144 (14)
52 (5.5)

8. In-Hospital Outcomes Stratified by Age
Age, years
<70
(n=2,394)
70-79
(n=1,031)
80-89
(n=941)
90
(n=202)
P Value
For Trend
All-cause mortality, %
31 (1.3)
36 (3.5)
95 (10)
48 (24)
<0.001
Cardiovascular mortality, %
26 (1.1)
24 (2.3)
78 (8.3)
39 (19)
Stroke, %
6 (0.3%)
3 (0.3%)
13 (1.4%)
4 (2.0%)
Cardiogenic shock, %
53 (2.2)
28 (2.7)
31 (3.3)
8 (4.0)
0.03
Mechanical ventilation, %
80 (3.3)
44 (4.3)
47 (5.0)
10 (5.0)
0.02
Heart failure, %
133 (5.6)
104 (10)
140 (15)
42 (21)
Ventricular arrhythmia, %
125 (5.2)
41 (4.0)
30 (3.2)
0.01
Brady-arrhythmia, %
38 (1.6)
31 (1.0)
27 (2.9)
6 (3.0)
Acute Kidney Injury
172 (7.2)
172 (17)
244 (26)
65 (32)
Nosocomial infection
30 (1.3)
18 (1.7)
20 (2.1)
0.001
Length of hospitalization,days
5 (3-7)
6 (4-11)
8 (5-14)
8 (5-15)
More than 5 days
898 (38)
556 (55)
622 (67)
148 (74)

9. Independent Predictors of All-Cause Mortality and Invasive Strategy
OR for all-cause mortality
(95% CI)
P values
for all-cause mortality
OR for invasive strategy
for invasive strategy
Age (continuous)
1.05 ( )
0.002
0.92 ( )
<0.001
Female
2.95 ( )
0.001
0.62 ( )
MVD
2.13 ( )
0.05 NA
In-hospital PCI
0.28 ( )
In-hospital CABG
0.21 ( )
0.009
Cardiogenicshock
11.65 ( )
Mechanical ventilation
6.61 ( )
Acute kidney injury
5.52 ( )
Ventricular arrhythmia
Diabetes mellitus
Prior CABG
Chronic kidney disease
Admission Hb <100 gm/L
STEMI
1.24 ( )
 NA
0.01
0.74 ( )
0.61 ( )
0.33 ( )
0.53 ( )
 2.14 ( )
0.004
 <0.001

10. In-Hospital Outcomes stratified by invasive vs conservative strategy
Unadjusted Rate
Inverse Probability Weighted
In-Hospital Outcome
Age, yrs
Conservative
(%)
Invasive
P Value
Odds Ratio of invasive strategy compared to conservative strategy
95% CI
All-cause mortality, (%)
<70
70-79
80-89
90
7 (3.8)
13 (7.4)
67 (15)
41 (25)
24 (1.1)
23 (2.7)
28 (5.5)
7 (18)
0.002
<0.001
0.30
3.7
9.0
15.3
25.7
1.1
2.9
6.2
17.3
0.30 ( )
0.30 ( )
0.37 ( )
0.60 ( )
0.036
CV death, (%)
6 (3.3)
8 (4.6)
53 (12.1)
34 (21.0)
20 (0.9)
16 (1.9)
25 (5.0)
5 (13.0)
0.003
0.03
0.22
3.3
12.1
21.3
0.9
2.0
5.7
12.7
0.28 ( )
0.32 ( )
0.44 ( )
0.54 ( )
0.021
Stroke
0 (0.0)
2 (1.1)
6 (1.4)
3 (1.9)
6 (0.3)
1 (0.1)
7 (1.4)
1 (2.5)
0.48
0.02
0.99
0.79
0.0
1.5
1.6
0.6
0.1
1.4
2.5
-NA
0.07 ( )
0.87 ( )
1.72 ( ) -
0.85
0.50
TIMI major
6 (3.4)
13 (3.0)
68 (3.1)
41 (4.8)
3 (7.5)
0.89
0.43
0.12
0.06
3.6
4.5
2.7
3.1
4.8
4.4
9.6
0.87 ( )
1.07 ( )
1.65 ( )
5.26 ( )
0.37
0.73
0.05
0.001
TIMI minor
16 (3.7)
7 (4.3)
80 (3.6)
35 (4.1)
24 (4.8%)
0.80
0.68
0.41
0.40
4.0
4.1
4.2
7.1
0.89 ( )
1.55 ( )
1.45 ( )
1.85 ( )
0.45
0.09
0.14
0.19

11. In-Hospital Outcomes stratified by invasive vs conservative strategy

12. In-Hospital Outcomes stratified by invasive vs conservative strategy

13. Limitations Retrospective design
Unmeasured confunding variables (frailty, cognitive impairment, physiological age)
202 Nonagenarians: but still the largest study to date

14. Conclusion Nonagenarians ACS patients:
Disctinct population (survival biais)
Very high in-hospital mortality (24%)
Less likely to undergo invasive strategy (20%)
After inverse probability weighted analysis:
Invasive strategy is associated with a lower All-cause/CV death
The absolute benefit of invasive strategy increase with age
Invasive strategy is associated with higher rate of major bleeding in patients >80 yo. Despiste this, there is still a mortality benefit.

15. Thank You

16. Inverse Probability Weighted
Deb et al. Canadian Journal of Cardiology 32 (2016) 259e265