elderly patients presenting with st - segment elevation myocardial infarction ( stemi ) are less likely to receive reperfusion therapies , both fibrynolysis and primary percutaneous coronary intervention ( pci ) [ 13 ] .
common reasons for excluding older patients from reperfusion therapy are their delayed presentation and atypical symptoms .
also , up to 9 % of elderly patients have absolute contraindication to fibrynolytic therapy . nowadays ,
primary pci is the preferred method of reperfusion for stemi , also in elderly patients .
it has been shown to be more effective than fibrynolysis in reduction of ischemic events in patients 75  years old with stemi with chest pain < 6  h . however , primary pci carries a decreased success rate and an increased procedural risk in older patients when compared with younger ones .
elderly stemi patients are also at the higher risk of death or other adverse ischemic and non - ischemic events as result of higher prevalence of comorbidities .
elderly patients with stemi are often excluded from randomized clinical trials , thus it is hard to generalize expected outcomes from randomized clinical trials to the real life setting .
more reliable data on treatment and outcomes of elderly patients with stemi can be extracted from multicenter registries .
the objective of the present study was to assess whether there exist age - dependent differences in the clinical characteristics , treatment strategies and clinical outcomes in patients with stemi transferred for primary pci based on data from the european registry on patients with st - elevation mi transferred for mechanical reperfusion with a special focus on upstream use of abciximab ( eurotransfer ) registry [ 79 ] .
the details of the eurotransfer registry ( clinicaltrials.gov number nct00378391 ) protocol and main results have been previously published [ 79 ] . in this
registry data concerning treatment and outcomes of 1,650 consecutive , transferred stemi patients in 15 stemi hospital networks from 7 european countries between november 2005 and january 2007 were collected . for the purpose of this analysis patients were divided into four age groups ( < 65 , 6574 , 7584 and 85  years of age ) .
the study protocol and execution complied with the declaration of helsinki and has been approved by the institutional review board .
all - cause death , reinfarction and urgent revascularization ( pci or coronary artery bypass grafting ) and bleeding complications : puncture site hematoma , intracranial hemorrhage , major bleeding requiring transfusion were evaluated during 30-day follow - up . additionally 1-year mortality was assessed .
data concerning thrombolysis in myocardial infarction ( timi ) flow in the infarct - related artery before and after pci , st - segment resolution after pci , and rate of pci complications ( no - reflow , distal embolization , side branch occlusion , artery perforation ) were also provided .
results were presented as percentages of patients or medians ( inter - quartile range ) .
differences in dichotomous variables were analyzed using chi - square test and the fisher s exact test as appropriate .
the difference in death rates between groups during follow - up period was assessed by the kaplan  meier method using the log - rank test .
in addition , multivariate cox regression analysis was performed to find significant predictors of 30-day death .
all tests were two - tailed and a p value of < 0.05 was considered statistically significant .
patients < 65 , 6574 , 7584 , and 85  years of age comprised 49.3 , 27.5 , 20.2 , and 3.0 % of the registry population , respectively .
characteristics of patient population according to age are shown in table  1 . the prevalence of female gender , diabetes mellitus , previous myocardial infarction , previous heart failure symptoms , previous stroke , current smoking and chronic kidney disease , as well as body mass index and diastolic blood pressure changed across age groups.table  1baseline demographics and clinical status on admission to percutaneous coronary intervention center stratified by agevariableage ( years)p value<65 ( n  =  814)6575 ( n  =  454)7585 ( n  =  333)85 ( n  =  49)male82.170.354.740.8<0.0001body mass index ( kg / m)26.9 ( 24.429.9)27.1 ( 24.829.7)25.7 ( 23.528.4)24.1 ( 22.426.7)<0.0001diabetes mellitus11.918.721.914.3<0.0001previous myocardial infarction8.616.116.818.4<0.0001previous heart failure symptoms0.41.83.300.001previous percutaneous coronary intervention6.9796.10.65previous coronary artery bypass grafting0.92.40.920.094previous stroke2.24.84.28.20.013current smoker5522.912.92<0.0001peripheral arterial disease2.73.5310.20.064chronic kidney disease1.02.93.94.10.004heart rate on admission ( beat / min)78 ( 6888)78 ( 6890)76 ( 6588)75 ( 6590)0.50systolic blood pressure on admission ( mmhg)130 ( 150120)126 ( 117156)135 ( 115152)134 ( 116166)0.58diastolic blood pressure on admission ( mmhg)80 ( 7091)80 ( 7090)75 ( 6585)80 ( 6490)<0.0001killip iv on admission2.73.33.36.10.78values are presented as percentages or medians ( inter - quartile range ) baseline demographics and clinical status on admission to percutaneous coronary intervention center stratified by age values are presented as percentages or medians ( inter - quartile range ) data concerning pharmacological and interventional treatment are summarized in table  2 .
elderly patients has experienced longer delays to individual stages of treatment than their younger counterparts ( table  2 ) and they were less likely to be treated with diagnosis - to - balloon time < 90  min ( for age < 65 , 6574 , 7584 , and 85 percentage of patients with diagnosis - to - balloon time < 90  min was as follows : 40.8 , 34.1 , 35.1 , 34.7 % , p  =  0.079 ) .
there was no difference in the frequency of unfractionated heparin and abciximab use across age groups , both in pre - cathlab and in the cathlab setting .
however , a trend toward less frequent administration of clopidogrel in older patients was observed ( table  2).table  2concomitant medications , timing information and invasive treatment details stratified by agevariableage ( years)p value<65 ( n  =  814)6575 ( n  =  454)7585 ( n  =  333)85 ( n  =  49)pain - to - diagnosis time ( min)96 ( 52198)111 ( 60213)132 ( 68240)97 ( 47303)<0.0001diagnosis - to - balloon time ( min)100 ( 77138)109 ( 83155)109 ( 80145)110 ( 67154)0.010admission to cathlab - to - balloon time ( min)30 ( 2041)31 ( 2145)32 ( 2344)33 ( 2047)0.11pain - to - balloon time ( min)216 ( 150329)240 ( 165377)251 ( 168379)200 ( 155425)<0.0001clopidogrel pre - cathlab33.732.828.822.40.19clopidogrel in the cathlab46.746.948.336.70.38unfractionated heparin pre - cathlab68.267.269.469.40.93unfractionated heparin in the cathlab61.363.761.9510.37abciximab pre - cathlab43.546.942.934.70.12abciximab in the cathlab23.521.217.726.5no abciximab3331.939.438.8femoral access86.484.488.387.80.45ira in baseline angiography  lmca1.20.20.620.15  lad42.145.24846.90.30  lcx13.311.911.110.20.71  rca42.440.138.140.80.59multi - vessel disease42.555.164.375.5<0.0001abandoned pci5.75.510.216.30.002immediate pci94.394.589.883.7number of patients undergoing immediate pci ( n)76842929941stent94.893.588.682.90.001  drug - eluting stent27.924.519.79.80.005  > 1 stent in ira2120.423.426.50.85thrombectomy12.211.710.412.20.86non - ira pci45.45.74.90.55pci complications ( no - reflow , distal embolization , side branch occlusion , artery perforation)7.39.314.414.60.003intra - aortic balloon pumping3.44.74.32.40.69values are presented as percentages or medians ( inter - quartile range)ira infarct - related artery , lad left anterior descending , lcx circumflex artery , lmca left main coronary artery , pci percutaneous coronary intervention , rca right coronary artery concomitant medications , timing information and invasive treatment details stratified by age values are presented as percentages or medians ( inter - quartile range ) ira infarct - related artery , lad left anterior descending , lcx circumflex artery , lmca left main coronary artery , pci percutaneous coronary intervention , rca right coronary artery in the coronary angiography prevalence of multivessel disease increased with age .
a total of 1,537 patients ( 93.2 % of study population ) underwent immediate pci .
elderly patients were more likely to be treated conservatively after coronary angiography and were less likely to receive stents , especially drug - eluting stents during immediate pci ( table  2 ) .
timi grade 3 flow frequency before pci was similar among age groups , but elderly patients were less likely to achieve optimal epicardial flow ( timi grade 3 flow ) after pci , and were more likely to have pci complications than their younger counterparts ( fig .  1 ; table  2 ) .
similarly , rate of st - segment resolution > 50 % after pci has shown age-dependency.fig . 
1thrombolysis in myocardial infarction flow before and after pci , and st - segment resolution > 50 % frequency in 1,537 patients undergoing immediate percutaneous coronary intervention stratified by age .
pci percutaneous coronary intervention , str st - segment resolution , timi thrombolysis in myocardial infarction thrombolysis in myocardial infarction flow before and after pci , and st - segment resolution > 50 % frequency in 1,537 patients undergoing immediate percutaneous coronary intervention stratified by age .
pci percutaneous coronary intervention , str st - segment resolution , timi thrombolysis in myocardial infarction as shown in fig . 
2a , the rates of death , death  +  reinfarction and all major adverse cardiovascular events at 30  days were increased with age .
in contrast , incidences of reinfarction and urgent revascularization at 30  days were independent of age .
the kaplan  meier curves for survival according to age are shown in fig . 
3 . in cox regression analysis , independent predictors of 30-day death were : age , diabetes mellitus , previous stroke , heart rate on admission , systolic blood pressure on admission , cardiogenic shock ( killip iv ) on admission , diagnosis - to - balloon time , stent implantation during pci , drug - eluting stent implantation during pci , non - infarct - related artery pci , left anterior descending artery as infarct - related artery , timi grade 3 flow after pci , st - segment resolution > 50 % after pci and major bleeding requiring transfusion ( table  3).fig . 
2ischemic events a ( death , death  +  reinfarction , death  +  reinfarction  +  revascularization ) and bleeding events b ( puncture site hematoma , intracranial hemorrhage , major bleeding requiring transfusion , total bleeding events ) at 30-day follow - up stratified by age .
3one - year kaplan  meier survival curves stratified by agetable  3multivariate cox regression analysis for 30-day deathvariablehazard ratio95% confidence intervalp valueage ( per 1  year)1.0491.0261.072<0.0001diabetes mellitus1.8791.0743.2880.027previous stroke3.1181.3117.4160.010heart rate on admission ( per 1  beat / min)1.0251.0131.038<0.0001systolic blood pressure on admission ( per 1  mmhg)0.9830.9730.9930.001killip iv on admission2.6811.3475.3370.005diagnosis to balloon time ( per 1  min)0.9950.9901.0000.035ira lad1.9711.1423.3990.015stent implantation during pci0.3690.1970.6890.002drug - eluting stent implantation during pci0.4010.1750.9180.031non - ira pci3.0551.4026.6570.005timi grade 3 flow after pci0.3960.2210.7090.002st - segment resolution > 50% after pci0.3520.2050.602<0.0001major bleeding requiring transfusion3.0571.0568.8450.039values are presented as hazard ratios with 95% confidence intervalsira infarct - related artery , lad left anterior descending , pci percutaneous coronary intervention , timi thrombolysis in myocardial infarction ischemic events a ( death , death  +  reinfarction , death  +  reinfarction  +  revascularization ) and bleeding events b ( puncture site hematoma , intracranial hemorrhage , major bleeding requiring transfusion , total bleeding events ) at 30-day follow - up stratified by age .
remi reinfarction one - year kaplan  meier survival curves stratified by age multivariate cox regression analysis for 30-day death values are presented as hazard ratios with 95% confidence intervals ira infarct - related artery , lad left anterior descending , pci percutaneous coronary intervention , timi thrombolysis in myocardial infarction as clearly shown in fig . 
2b there were no differences in the occurrence of puncture site hematoma and intracranial hemorrhage ( which did not occur in either group ) across age groups .
a trend toward higher risk of major bleeding requiring transfusion and significantly higher incidence of all bleeding complications in elderly patients ( especially 85  years of age ) were observed .
our study suggests that age is still an important determinant of treatment strategies selection , even in well - organized networks of stemi treatment .
elderly patients are treated less aggressively in terms of antiplatelet therapy , have experienced longer delays to successful reperfusion , and they are at higher risk of death during follow - up . in our study ,
similar to previous studies , and as expected , higher mortality rate was observed in older patients .
one of potential explanations of the short- and long - term clinical outcome worsening in elderly stemi patients is higher prevalence of comorbidities . in line with previous studies ,
elderly patients were more likely to have diabetes mellitus , previous myocardial infarction , previous heart failure symptoms , previous stroke , and chronic kidney disease [ 1 , 1014 ] .
older patients experienced longer time - delays to admission and primary pci , and presenting more frequently with acute heart failure symptoms .
another important risk factor for higher mortality in patients with acute coronary syndromes is the presence of renal function impairment [ 15 , 16 ] . preexisting impairment of renal function , diabetes mellitus and advanced age
are also associated with increased risk of contrast induced nephropathy development after coronary angiography and primary pci , which may led to worsening of long - term prognosis [ 17 , 18 ] .
elderly patients are also at higher risk of non - cardiac death during follow - up related to cancer or lung diseases .
similarly , to previous reports in our study observed frequency of reinfarction and need of repeated revascularization was comparable across age groups [ 1 , 10 ] .
it is well established that in elderly patients primary pci success rate is lower , with higher risk of angiographic complications than in younger counterparts [ 1214 ] . in our study ,
the frequency of optimal epicardial flow ( timi grade 3 flow ) after primary pci decreases with age .
in contrast , in the controlled abciximab and device investigation to lower late angioplasty complications ( cadillac ) trial correlation between final epicardial flow after pci and age was not observed .
the complex coronary anatomy observed in elderly patients may be associated with a higher incidence of distal embolization , which is a important determinant of myocardial perfusion after primary pci , as well as long - term clinical outcome [ 13 , 14 , 19 ] .
in addition , de luca et al . have found a relationship between increased age and impaired myocardial perfusion assessed by myocardial blush grade , and st - segment resolution .
the higher prevalence of multi - vessel disease and the fear of complications among elderly may account for more frequent selection of initial conservative approach , with postponed pci or coronary artery bypass grafting .
presence of multi - vessel disease in stemi patients influences the clinical outcomes of patients treated with primary pci .
also , as confirmed by our study patients with advanced age are less likely to be treated with drug - eluting stents in stemi setting . in the analyzed patients population
there was a trend toward higher rate of major bleeding requiring transfusion in patients with advanced age .
importantly , major bleeding occurrence is a strong predictor of short- and long - term mortality [ 2226 ] .
also , major bleeding may be associated with higher incidence of ischemic events , for example myocardial infarction , unplanned ischemic revascularization , and stent thrombosis .
an increased likelihood of the vascular access site complications ( hematomas or aneurysm ) in elderly patients is a result of the presence of calcified , fragile and bleeding prone vessels in these patients .
in addition , in elderly patients frequently reduced kidney function is leading to overdosing of antithrombotic drugs , and to the increased risk of bleeding .
access site bleeding complications could be decreased by broad usage of radial approach , which was used in < 15 % of patients in the eurotransfer registry .
safety and efficacy of transradial catheterization in the elderly is similar to observed in younger patients .
importantly , it may improve the comfort of the patients , especially in the context of the age - related diseases that frequently affect elderly patients .
however , advanced age was identified as an independent predictor of selection femoral over radial access by the operator during primary pci in our registry . also , a fear of bleeding may limit the use of antiplatelet agents , especially glycoprotein iib  iiia inhibitors in patients 75  years of age .
importantly , previous studies have shown that patients who present with an acute coronary syndrome and do not receive guideline - recommended therapies , including glycoprotein iib 
first , the study group is relatively small , and the very eldery patient subset ( 85  years of age ) comprised only 3 % of the study population . also , the study focused mainly on 30-day clinical outcomes .
secondly , patients were not screened for contraindications to use of each medication and appropriateness of used dosage was not assessed .
it is very likely that in some of patients various therapies were not used due to an important clinical reason .
the registry was conducted between november 2005 and january 2007 when new p2y12 inhibitors ( prasugrel , ticagrelor ) were not available . also , the frequency of bivalirudin monotherapy was rather low , as it was recommended as alternative to unfractionated heparin and glycoprotein iib 
thus , the study did not cover most contemporary pharmacological treatment patterns for stemi . on the other hand , since year 2007 there was no significant change in the recommendations concerning the application of primary pci in stemi setting .
finally , the interpretation of the timi flow grade measurements , as well as st - resolution was limited by the fact that these represent not independent core - lab , but physician s assessments .
age was an important determinant of treatment strategies selection and clinical outcomes in the group of consecutive stemi patients transferred for primary pci .
further efforts should be made to reduce delays and to optimize treatment of stemi , regardless of patients age .
 data concerning the benefits and risks of primary pci in the elderly patients presenting with st - segment elevation myocardial infarction ( stemi ) are limited . 
 thus , the objective of the study was to assess age - dependent differences in the treatment and outcomes of stemi patients transferred for primary pci . 
 data were gathered on 1,650 consecutive stemi patients from hospital networks in seven countries of europe from november 2005 to january 2007 ( the eurotransfer registry population ) . 
 patients < 65 , 65 to 74 , 75 to 84 , and 85  years of age comprised 49.3 , 27.5 , 20.2 , and 3 % of the registry population , respectively . 
 elderly patients were higher risk individuals and have experienced longer delays to reperfusion than their younger counterparts and were more likely to be treated conservatively after coronary angiography . despite similar frequency of timi 3 flow before pci , elderly patients were less likely to achieve timi 3 flow and st - segment resolution > 50 % after pci , and were more likely to have pci complications . 
 the rates of death at 30  days , as well as at 1  year were increased with age . in the cox regression analysis model age was an independent predictor of 30-day mortality . a trend toward higher risk of major bleeding requiring transfusion was observed . 
 age was an important determinant of treatment strategies selection and clinical outcomes in the group of consecutive stemi patients transferred for primary pci . 
 further efforts should be made to reduce delays and to optimize treatment of stemi , regardless of patients age . 
Background
Methods
Results
Discussion
Limitations of the study
Conclusions