Abstract
Those of advanced age are at increased risk of acute coronary syndromes, in particular myocardial infarction (Mehta et al., 2005). Furthermore, for the very old, morbidity and mortality outcomes following ST- elevation myocardial infarction (STEMI) are worse, physiological changes associated with aging and pathology changes and polypharmacy associated with comorbidities complicate disease cause and treatment. Interventions following STEMI are focused on myocardial reperfusion, the leading intervention being percutaneous coronary intervention (PCI), followed by thrombolysis. PCI is associated with reduced mortality, prevention of recurring myocardial infarction and stroke when compared with thrombolytic therapy in patients presenting with STEMI (Armstrong et al., 2013; Mehta et al., 2005; National Heart Foundation of Australia and The Cardiac Society of Australia and New Zealand, 2016).
Study Aim: The aim of this dissertation was to examine the published evidence regarding in-hospital mortality data in those 80 years and over following STEMI and treatment with tenecteplase.
Methods : An integrative literature review approach as described by Whittemore and Knalf (2005) was undertaken to answer the study aim. The literature search followed the PRISMA process, the Preferred Reporting Items for Systemic Reviews and Meta-analyses (Liberati et al., 2009). Following screening of identified articles, quality appraisal activities were applied using the Quality Appraisal Tool for studies with Diverse Designs (QATSDD) (Sirriyeh et al., 2001) which resulted in an article corpus of fourteen research articles for analysis. The approach to data analysis was based on Whittemore and Knafl (2005).
Findings: Analysis of the fourteen primary research articles identified five syntheses, informed from twelve categories, developed from 76 findings, the syntheses identified were as follows; treatment aim for STEMI, treatment options for STEMI, in-hospital prognosis, risk factors of the elderly patient and lack of studies involving the elderly. The influence of pre-existing conditions and in-hospital complications post STEMI were significant. The evidence reinforced PCI as the post STEMI intervention associated with best outcomes, regardless of patient age. Although, thrombolysis was shown to deliver equally satisfactory outcomes when administered within the first one to three hours following symptom on-set. These data identified important impediments to early, accurate diagnosis and timely reperfusion interventions for the older patient.
Discussion: The five main syntheses identified from these data showed that treatment definitely improves outcomes regardless of age, however, in the context of in-hospital mortality in the very old following STEMI is influenced by a variety of factors. In-hospital mortality data based on tenecteplase treatment cannot be restricted down to treatment strategy alone. Pooled comparison data between articles can be used to guide statistical information but validity and accuracy remain questionable in the clinical setting; treatment guidance is compounded by a lack of studies focusing only on the elderly cohort and ultimately ends with the attending clinicians' decision on treatment choice.
Conclusion: In taking into consideration the variables from the discussion, the in-hospital mortality of patients over the age of 80 years following a STEMI and treatment with tenecteplase have resulted in the conclusion that tenecteplase in the treatment of a STEMI definitely has a place in regards to treatment of the elderly patient, especially in the early stages of the event and when PCI capable facilities are not readily available.
Mortality data shows a conferred survival advantage over the conservative treatment strategy but less so when compared with PCI. The general inference is that there needs to be more clinical studies focused on the elderly population with a thorough explanation of all the variable factors involved. The elderly often have delayed presentation, which is one of the determining factors why patients are not given thrombolysis and a thorough in- depth look at why this occurs and how it can be prevented for this population is essential.
There needs to be more emphasis placed on the finding that the elderly frequently have atypical symptoms on presentation that delays diagnosis and impacts on outcomes and more education around this for clinicians in attending the elderly patient.