Address for correspondence:

Clinical Investigations Aleksander Goch, PhD

Department of Cardiology
Medical University of Lodz-Poland
Sterlinga 1/3; 91–425 Lodz, Poland
The Clinical Manifestation of Myocardial a.goch@termedia.pl

Infarction in Elderly Patients

Aleksander Goch, PhD; Paweł Misiewicz, MD; Jacek Rysz, MD, FASN, FASA, FSGC;
Maciej Banach, MD, FESC, FASA, FSGC
Department of Cardiology, 1st Chair of Cardiology and Cardiac Surgery, Medical University of
Lodz, Poland (Goch); Emergency Department, Specialist Hospital, Radom, Poland (Misiewicz);
Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Lodz,
Poland (Rysz); Department of Molecular Cardionephrology and Hypertension, Medical University
of Lodz, Lodz, Poland (Banach)

Background and Hypothesis: The study aimed to compare the clinical picture and treatment differences in
elderly patients (aged 75 years or older) and younger patients (aged below 75 years).
Methods: The study included 80 consecutive patients with myocardial infarction (MI) treated in the Cardiology
Ward of the Specialist Hospital in Radom, Poland, in 2005. Analyses were performed retrospectively. The
patients were separated into 2 groups according to age. The group I study group consisted of 40 patients
aged 75 or over (aged 75–95; mean 81 years) and the group II control group consisted of 40 patients aged
below 75 years (aged 42–67; mean 60 years).
Results: In the elderly, as compared with younger subjects, dyspnea, fatigue, and other heart failure symptoms,
were more frequently the first symptoms of MI than typical chest pain (p<0.05). ST-segment elevation
myocardial infarction (STEMI) was also more common (p<0.05). Non-ST-segment elevation myocardial
infarction (NSTEMI) was more frequently diagnosed in the elderly (p<0.05). In elderly patients there were
more women (p<0.05), more patients with previously diagnosed ischemic heart disease (p<0.05), with
hypertension (p<0.05), and with diabetes mellitus (p<0.05). Obesity was less frequently diagnosed in the
elderly; however the difference was not statistically significant. Dyslipidemia and cigarette smoking were both
significantly less common among elderly patients (p<0.05). The elderly were significantly less frequently
revascularized (p<0.05). Both fibrinolysis and primary percutaneous coronary intervention (PCI) were less
commonly applied to the elderly (p<0.05). Time from symptom onset to hospital admission was significantly
longer in the case of elderly patients (p<0.05). The MI complications and side effects of treatment seemed to
be more frequent in the elderly, but only post-MI heart failure was observed more frequently in this group of
patients (p< 0.05).
Conclusions: Our observations confirm the differences in the clinical picture of MI in the elderly as described
previously. All patients of advanced age should be considered as having the highest risk of death and
complications occurrence.

Introduction Longevity in developed countries has improved signifi-

Myocardial infarction (MI) remains the leading cause of
hospitalizations as well as the leading cause of death
worldwide. In Poland, more than 100,000 patients suffer
from MIs each year. A total of 25%–55% of these patients
die in the pre-hospital period, 7%–15% in the hospital, and
5%–10% within the following 12 mon.1 Both in-hospital and
long-term mortality are significantly higher in the elderly,
regardless of the type of treatment.2,3,4 In patients with
acute myocardial infarction (AMI) who are older than 70
years, mortality rates exceed 30%.5 Besides anterior MI,
heart rate >100 beats/min, overt heart failure, and systolic
blood pressure <100 mm Hg, age >70 years is one of the
predictors of poor outcome after MI.2,6
cantly in recent years. A large number of people with MIs
are older than 65 years and this number will be increasing.
It is estimated that the number of people aged >65 years
in 2015 will reach 540 million and in 2025 about 1 billion.
The process of societal aging is also seen in Poland. In 2004,
14.8% of the people in Poland were older than 65.7 According
to the United Nations these data classify Polish society as
an aging one. The percentage of elderly people in Poland is
predicted to increase up to 26% by 2030.
The incidence and prevalence of MI increase progres-
sively with age. In the United States, over 60% of acute MIs
occur in patients 65 years of age or older, and approximately
one third occur in persons over age 75.8 Coronary heart

E46 Clin. Cardiol. 32, 6, E46–E51 (2009)

Published online in Wiley InterScience. (www.interscience.wiley.com)
Received: August 30, 2007
Accepted with revision: November 25, 2007
DOI:10.1002/clc.20354  2009 Wiley Periodicals, Inc.
disease is more advanced in the elderly than in younger history must have been documented in medical reports
patients. Three-vessel disease occurred in 44% of subjects (discharge chart from a hospital).
with ischemic heart disease aged 65–74 and in 63% of
subjects aged 75 and over.9 Statistical analysis
The clinical features of acute MI vary by age in many The results are presented as the number of patients charac-
aspects. Because of the increasing burden on health care terized by the analyzed feature. Statistical significances of
systems associated with MIs in the elderly, differences the differences between the groups were examined by the
in clinical picture, and difficulties in dealing with elderly Student t test or Mann-Whitney U test (when data were not
patients with MI, we analyzed the course of MIs in the normally distributed). A p value <0.05 was assumed to be
group of patients aged 75 years or older hospitalized in statistically significant.
the Cardiology Ward of the Specialist Hospital in Radom in
2005. The aim of our study was to determine presentation, Results
cardiac-risk factors, and management strategies in the First, clinical symptoms of MI differed in the elderly as
elderly (≥75 years) compared with those in younger patients compared to younger patients. Chest pain was reported
(<75 years). less frequently (19 [47.5%] versus 32 [80%]; p<0.05) and
dyspnea or fatigue was reported more frequently (18 [45%]
Materials and Methods versus 7 [17.5%]; p<0.05) by the elderly (Table 1). Also,
The study included 80 consecutive patients with MIs treated electrocardiographic presentation differed in the elderly.
in the Cardiology Ward of the Specialist Hospital in Radom ST-elevation was less frequently detected in the elderly
in 2005. Analyses were performed retrospectively. MI was (21 [52.5%] versus 26 [65%]; p<0.05), while ST-depression
defined according to the European Society of Cardiology was more frequently detected (15 [35%] versus 11 [27.5%];
(ESC) definition from 2000,10 by the significant elevation of p<0.05). The differences were statistically significant. LBBB
myocardial necrosis markers (troponin T/CK-MB) in addi- and negative T-waves tended to be more frequent in
tion to a history compatible with MI, electrocardiographic the elderly, but the differences did not reach statistical
abnormalities, or both. The history compatible with MI significance (p>0.05) in our observations. MI with LBBB
was defined as the presence of anginal chest pain lasting occurred in 3 elderly and 2 younger patients (Table 1).
more than 30 min. The electrocardiographic abnormalities In elderly patients there were more women (p<0.05),
were defined as: ≥1 mm ST-segment elevation in contigu- more patients with previously diagnosed ischemic heart
ous leads; ≥1 mm ST-segment depression; definite T-wave disease (p<0.05), with hypertension (p<0.05), and with
inversion; evolution of pathologic Q-waves (≥0.04 sec); or diabetes mellitus (p<0.05). Obesity was less frequently diag-
new left bundle branch block (LBBB). nosed in the elderly, but the difference was not statistically
The patients were separated into 2 groups according to
age. The group I study group consisted of 40 patients aged Table 1. MI symptoms and MI ECG presentation
75 or over (aged 75–95; mean 81 years) and the group II
MI symptoms Age ≥75 Age <75 p value
control group consisted of 40 patients aged below 75 years
(aged 42–67; mean 60 years). In this article, we have defined Chest pain 19 (47.5%) 32 (80%) p<0.05
elderly patients as being 75 or older. ST-segment elevation
(Typical/atypical/ 11/6/2 21/8/3 –
myocardial infarction (STEMI) occurred in 47 cases.
non-characteristic)∗ 27.5/15/5% 52.5/20/7.5%
All patients received standard therapy according to the
ESC standards and according to clinical setting. Dyspnea/fatigue 18 (45%) 7 (17.5%) p<0.05
Hypertension was defined according to JNC VII (the
Other symptoms∗∗ 3 (7.5%) 1 (2.5%) NS
seventh report of the Joint National Committee on Preven-
tion, Detection, Evaluation, and Treatment of High Blood ECG changes
Pressure)7 criteria (2 measurement values of blood pressure
STEMI 21 (52.5%) 26 (65%) p<0.05
≥140/90 mm Hg, or patient was on hypotension therapy
before MI). Dyslipidemia was defined according to ESC pre- NSTEMI 14 (35%) 11 (27.5%) p<0.05
vention guidelines11 (total cholesterol ≥190 mg/dl and/or
Acute LBBB 3 (7.5%) 2 (5%) NS
triglycerides ≥150 mg/dl, or patient was on hypolipidemic
therapy—statins/fibrates before MI). Obesity was defined ∗
Typical pain: 3 features, atypical pain: 2 features, non-characteristic
based on the body mass index ≥30 kg/m2 . Diabetes melli- pain: 1 feature of coronary pain.10 ∗∗ Other symptoms: anxiety, sweating,
tus (DM) was diagnosed if patient suffered from DM before palpitations. Abbreviations: ECG = electrocardiogram; LBBB = left
MI. The patient was assumed to be an addictive smoker if bundle branch block; MI = myocardial infarction; NSTEMI = non-ST-
segment elevation myocardial infarction; STEMI = ST-segment elevation
he/she smoked actively before MI. All episodes of ischemic
myocardial infarction.
heart disease and the episodes of invasive procedures in

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A. Goch et al.: Myocardial infarction in the elderly
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DOI:10.1002/clc.20354  2009 Wiley Periodicals, Inc.
 Clinical Investigations continued

significant. A family history of ischemic heart disease, PCI was performed on 42 patients in total, on 17 (44%) and 24
dyslipidemia, and cigarette smoking were significantly less (60%) of groups I and II, respectively. Elderly patients these
common (p<0.05) among elderly patients (Table 2). 2 invasive procedures performed—coronary angiography
Elderly patients had suffered from previous MIs more and PCI—significantly less frequently when compared to
frequently (p<0.05) and they had undergone coronary younger patients (p<0.05; Table 4).
angiography and PCI less frequently (p<0.05). Only 1 During the course of hospitalization, elderly patients
patient over 75 had had coronary artery bypass graft surgery rarely received angiotensin converting enzyme inhibitors
compared to none in the group of younger patients. There (ACE-I; p<0.05). Low molecular weight heparin was
was statistical significance in the higher frequency of elderly more often administered (p<0.05). Other medications
patients having been diagnosed with ischemic heart disease like aspirin, clopidogrel, beta-blockers, and unfractionated
before MI (p<0.05; Table 3). heparin (UFH), were used in both groups with the same
A total of 25 (31%) patients received thrombolytic treat- frequency (Table 5). As to MI complication, only recurrent
ment: 14 (34%) elderly and 11 (27%) younger patients, but the MI occurred more frequently in the elderly (p<0.05)
differences were not statistically significant (p>0.05). Coro- (Table 6).
nary angiography was performed on 54 (67.5%) patients in The time duration from symptom onset to hospital
total, on 20 (50%) and 34 (85%) of groups I and II, respectively. admission was significantly longer in the case of elderly
patients (p<0.05; Table 7). Mean time for the elderly was
5 h and 56 min contrasted to 3 h and 45 min for younger
Table 2. Cardiac risk factors profile
patients.
Risk factors Age ≥75 Age <75 p value The MI complications and side effects of treatment
seemed to be more frequent in the elderly, but only post-MI
Women 21 (52%) 14 (35%) p<0.05
heart failure was observed more frequently in patients of
Men 19 (65%) 26 (65%) p<0.05 group I (p<0.05).
Smoking 8 (20%) 21 (52%) p<0.05
Table 4. Reperfusion therapy
Hyperlipidemia 14 (35%) 17 (42%) p<0.05
Reperfusion therapy Age ≥75 Age <75 p value
History of IHD 28 (70%) 24 (60%) p<0.05
Thrombolysis 14 (34%) 11 (27%) NS
Hypertension 22 (55%) 18 (45%) p<0.05
Coronary angiography 20 (50%) 34 (85%) p<0.05
Diabetes mellitus 12 (30%) 5 (12%) p<0.05
PCI 17 (44%) 24 (60%) p<0.05
Obesity∗ 11 (27%) 12 (30%) NS
CABG 2 (5%) 1 (2.5%) NS
Family history∗∗ 8 (20%) 18 (45%) p<0.05
Abbreviations: CABG = coronary artery bypass grafting; PCI =
Abbreviation: IHD = ischemic heart disease. ∗ Obesity was defined as percutaneous coronary intervention.
BMI (body mass index) ≥30 kg/m2 . ∗∗ Family history is defined as any
clinical atherosclerosis in the family diagnosed in females before 65 and
in males before 55 years old.
Table 5. Medical treatment of MI

Medical treatment Age ≥75 Age <75 p value

Table 3. Episodes of ischemic heart disease and the episodes of invasive
procedures in history ASA 39 37 NS

History of IHD Age ≥75 Age <75 p value Clopidogrel 28 30 NS

MI 9 (23%) 6 (16%) p<0.05 ACE-I 26 21 p<0.05

Coronary angiography 2 (5%) 5 (12%) p<0.05 AT 1 antagonists 7 5 NS

PCI 2 (5%) 4 (10%) p<0.05 Beta-blockers 19 21 NS

CABG 1 (2.5%) 0 NS UFH 23 23 NS

IHD 28 (70%) 24 (60%) p<0.05 LMWH 5 12 p<0.05

Abbreviations: CABG = coronary artery bypass grafting; IHD = ischemic Abbreviations: ACE-I = angiotensin converting enzyme inhibitors; ASA
heart disease; MI = myocardial infarction; PCI = percutaneous coronary = aspirin; AT1 = antiotensin type 1 receptor; LMWH = low molecular
intervention. weight heparin; UFH = unfractionated heparin.

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A. Goch et al.: Myocardial infarction in the elderly
Published online in Wiley InterScience. (www.interscience.wiley.com)
DOI:10.1002/clc.20354  2009 Wiley Periodicals, Inc.
Table 6. MI complications in the acute phase of MI.14,16 Even when classic ischemic
MI complications Age ≥75 Age <75 p value precordial discomfort is present, it tends to be less severe
and less well defined. The elderly appear to have reduced
Cardiogenic shock 5 (12%) 7 (18%) NS
pain perception.17 This phenomenon may result from the
Pulmonary edema 7 (18%) 9 (23%) NS increase of pain threshold of permanently ischemic sen-
sory nerves, ischemic dysfunction of the cerebral cortex,
VT/VI 10 (25%) 13 (33%) NS
and dysfunction of the autonomic nervous system.18 The
Recurrent MI 3 (8%) 5 (12%) p<0.05 last one is very likely exemplified in that the elderly who
did not describe chest pain also did not describe sweating,
Post-MI unstable angina pectoris 4 (10%) 5 (12%) NS
nausea, and vomiting.19 The older the population, the more
Heart failure* 5 (12%) 11 (27%) NS frequently the symptoms of heart failure exacerbation were
described in the acute phase of MI.20 Typical symptoms of
Stroke 1 (2.5%) 1 (2.5%) NS
chronic heart failure exacerbation were often accompanied
Serious bleeding 1 (2.5%) 2 (5%) NS by mental disorders, dizziness, presyncope, and syncope.20
Older patients are also more likely to have ‘‘silent’’ or
Death 2 (5%) 5 (12%) NS
unrecognized MIs compared to younger patients. These
Abbreviation: MI = myocardial infarction. ∗ Heart failure is defined as facts often result in delays in MI diagnosis in the elderly. The
clinical symptoms (rest dyspnea) and/or physical signs (pulmonary length of time from symptom onset to hospital admission
congestions) on the admission or ejection fraction (EF)<45% in was significantly longer for the elderly compared to the
echocardiography performed on the discharge. younger patients in our study (5 h 56 min versus 3 h 45
min). Such trends have been observed previously.21
Table 7. Time from symptom onset to hospital admission Apart from clinical presentation in the acute phase
of MI, the cardiac risk factor profile of elderly patients
Time Age ≥75 Age <75 p value
with MI is different. Older patients are mostly women
Time <1 h 3 (8%) 8 (20%) p<0.05 with a history of heart failure and MI, and risk factors
are predominantly diabetes mellitus and hypertension.
Time <2 h 10 (25%) 18 (44%) p<0.05
Smoking, dyslipidemia, and family history seem not to be
Time <6 h 14 (35%) 11 (28%) NS very important or widespread risk factors in the elderly. A
better understanding of the prevalence of various risk factors
Time >6 h 13 (32%) 3 (8%) p<0.05
among patients with MI may help to develop secondary
prevention programs to target different age groups with
different preventive methods.
Discussion
It was documented previously that with increasing age,
The clinical picture of MI in elderly patients differs in
the gender composition of patients with MI changed.5,22
many aspects as compared to younger patients. The factors
In middle-aged patients men dominate, whereas in patients
affecting the course of MI in the elderly have not been
aged 75 and over the definite predominance of women was
studied in detail. Clinical studies have incorporated very
revealed. Female predominance among the elderly is the
limited numbers of the elderly, since most of the studies
result of their longer lifespan in comparison to men.
excluded people over 65 years old,12,13 and some did not
Despite the fact that older patients constitute the group
have more than 10% older people.14
In the elderly, numerous disorders often coexist. of high coronary risk and that numerous observations and
Ischemic heart disease, hypertension, diabetes mellitus, studies proved that these patients benefit significantly from
chronic obstructive pulmonary disease, chronic renal fail- PCI in acute MI,23,24,25 invasive procedures in this group of
ure, digestive system disorders, as well as, joint and bone patients are performed relatively rarely. This was consistent
disorders occur more often in this group of patients. The with our observations. PCI was performed in 17 (44%)
coexistence of several diseases may cause the clinical pic- elderly patients and 24 (60%) younger ones, which made
ture of acute coronary syndrome to be uncharacteristic. In the difference statistically significant. Even thrombolysis
the first hours of MI, the elderly are more likely to com- is applied less frequently in the elderly because of the
plain about symptoms other than typical coronary chest threat of bleeding complications and the diagnosis delay
pain. They often describe dyspnea, fatigue, and dizziness. that causes exceeding of the therapeutic ‘‘window’’ of 12
Confusion or altered mental status may be the presenting h. Although several studies26,27 proved that elderly patients
manifestation of acute MI in up to 20% of patients over benefit from reperfusion therapy,23,24,25 they received both
85 years of age.15 It was observed previously that 75% of thrombolytic and invasive procedures less frequently when
patients over 85 with MIs did not complain about chest pain compared with younger patients. This paradox phenomenon

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A. Goch et al.: Myocardial infarction in the elderly
E49
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DOI:10.1002/clc.20354  2009 Wiley Periodicals, Inc.
 Clinical Investigations continued
was observed in many clinical studies and registries27 and
was confirmed in our small sample as well.
In the previous observations, an increasing gradient of
mortality with increasing age was seen.20 In our study, 5
patients of the elderly group and 2 of the younger individuals
died in the hospital. The differences were not statistically
significant. The incidence of recurrent angina was observed
previously20 to be less frequent in the elderly. Such a trend
was also observed in our study, but it was not statistically
significant. The only statistically significant difference in
post-MI complications between the elderly and younger
patients was a higher incidence of post-MI heart failure.28
Limitations of the Study
The retrospective nature of the study is an obvious
methodological limitation. We also realized that the number
of patients in the study groups was small, which significantly
limits our conclusions from the observations. However,
the results of our observations are consistent with those
reported previously.
In conclusion, our observations confirmed the differences
in the clinical picture of MI between older and younger
individuals in many aspects. The elderly present less typical
symptoms of MI, which is followed by the significant delay
in diagnosis and initiation of the treatment. This group
also has different cardiac risk factor profile characteristics.
Despite the fact that the elderly constitute a group at
high cardiovascular risk, the most effective methods of
MI treatment, such as reperfusion procedures including
PCI, are performed significantly less often when compared
to younger MI patients. The majority of differences noticed
in our small sample have been observed previously.
References
1. Kitazume H, Kubo I, Iwama T, Ageishi Y, Suzuki A. Percutaneous
transluminal coronary angioplasty for elderly patients. Circ J.
1988;52:449–453.
2. Batchelor WB, Anstrom KJ, Muhlbaier LH, et al. Contemporary
outcome trends in the elderly undergoing percutaneous coronary
interventions: results in 7,472 octogenarians. J Am Coll Cardiol.
2000;36:723–30.
3. DeGeare VS, Stone GW, Grines L. Angiographic and clinical
characteristics associated with increased in-hospital mortality
in elderly patients with acute myocardial infarction undergoing
percutaneous intervention (A pooled analysis of the primary
angioplasty in myocardial infarction trials). Am J Cardiol.
2000;86:30–34.
4. Lee KL, Woodlief LH, Topol EJ, et al. Predictors of 30-day
mortality in the era of reperfusion for acute myocardial infarction:
results from an international trial of 41,021 patients. Circulation.
1995;91:1659–1668.
5. Devlin W, Cragg D, Jacks M. Comparison of outcome in patients
with acute myocardial infarction aged 75 years with that in younger
patients. Am J Cardiol. 1995;75:573–576.
6. Grines CL, Westerhausen DR, Grines LL, et al; Air PAMI Study
Group. A randomized trial of transfer for primary angioplasty
versus on-site thrombolysis in patients with high-risk myocardial
infarction: the air primary angioplasty in myocardial infarction
study. J Am Coll Cardiol. 2002;39(11):1713–1719.
E50 Clin. Cardiol. 32, 6, E46–E51 (2009)
A. Goch et al.: Myocardial infarction in the elderly
Published online in Wiley InterScience. (www.interscience.wiley.com)
DOI:10.1002/clc.20354  2009 Wiley Periodicals, Inc.
7. Kowalski J, Banach M, Barylski M, et al. Neutrophil superoxide
anion generation during atorvastatin and fluvastatin therapy
used in coronary heart disease primary prevention. J Cardiovasc
Pharmacol. 2006;48:143–147.
8. Rich MW. Epidemiology, clinical features, and prognosis of
acute myocardial infarction in the elderly. Am J Geriatr Cardiol.
2006;15:7–11.
9. Thompson RC, Holmus DR Jr, Gersh BJ, Mock MB, Bailey
KR. Percutaneous transluminal coronary angioplasty in the
elderly: early and long term results. J Am Coll Cardiol. 1991;17:
1245–1250.
10. Myocardial infarction redefined: a consensus document of The
Joint European Society of Cardiology/American College of
Cardiology Committee for Myocardial Infarction Redefinition. Eur
Heart J. 2000;21:1502–1513.
11. De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European
guidelines on cardiovascular disease prevention in clinical practice:
Third joint task force of European and other societies on
cardiovascular disease prevention in clinical practice. European
Heart J. 2003;24:1601–1610.
12. AIMS Trial Study Group. Effect of intravenous APSAC on mortality
after acute myocardial infarction: preliminary report of a placebo
controlled trial. Lancet. 1989;1:545–549.
13. Chesbro JH; TIMI Investigators. Thrombolysis in Myocardial
Infarction (TIMI) trial. Phase I: a comparison between intravenous
tissue plasminogen activator and intravenous streptokinase.
Circulation. 1987;76:142–154.
14. Akiyama J, Aonuma K, Nogami A, et al. Thrombolytic therapy
can reduce the arrhythmogenic substrate after acute myocardial
infarction: a study using the signal-averaged electrocardiogram,
endocardial catheter mapping and programmed ventricular
stimulation. Circ J. 1999;63:838–842.
15. Banach M, Drożdż J, Okonski P, Rysz J. Immunological aspects
of the statins’ function in patients with heart failure: a report from
the Annual Conference of ESC—Heart Failure 2005. Cell Mol
Immunol. 2005;2:433–437.
16. Muller RT, Gould LA, Betzu RY, Vacek T, Pradeek V. Painless
myocardial infarction in the elderly. Am Heart J. 1990;119:
202–204.
17. Gregoratos G. Clinical manifestations of acute myocardial
infarction in older patients. Am J Geriatr Cardiol. 2001;10:
345–347.
18. Miller PF, Sheps DS, Bragdon EE, et al. Aging and pain perception
in ischemic heart disease. Am Heart J. 1990;12:22–27.
19. Bayer AL, Chadha JS, Farag RR, Pathy MS. Changing presentation
of myocardial infarction with increasing old age. J Am Geriatr Soc.
1986;34:263–269.
20. Paul DS, O’Gara PT, Mahjoub ZA, et al. Geriatric patients with
acute myocardial infarction: cardiac risk profiles, presentation,
thrombolysis, coronary interventions, and prognosis. Am Heart J.
1996;131:710–715.
21. Haase KK, Schiele R, Wagner S, et al. In-hospital mortality of
elderly patients with acute myocardial infarction: data from MITRA
(Maximal Individual Therapy in Acute Myocardial Infarction)
registry. Clin Cardiol. 2000;23:831–836.
22. Smith SC, Gilpin E, Ahnve S, et al. Outlook after acute myocardial
infarction in the very elderly compared with that in patients aged
65 to 75 years. J Am Coll Cardiol. 1990;16:784–792.
23. Matetzky S, Sharir T, Moc M, et al. Primary angioplasty for
acute myocardial infarction in octogenarians. Am J Cardiol.
2001;88:680–683.
24. Banach M, Goch A, Misztal M, et al. Low output syndrome
following aortic valve replacement: predictors and prognosis. Arch
Med Sci. 2007;3:117–122.
25. Harpaz D, Rozenman Y, Behar S, et al. Israeli Working Group on
Intensive Cardiac Care, Israel Heart Society: coronary angiography
 in the elderly with acute myocardial infarction. Int J Cardiol.
2007;116:249–256.
26. Kosuge M, Kimura K, Kojima S, et al. Japanese Acute
Coronary Syndrome Study (JACSS) Investigators: beneficial
effect of preinfarction angina on in-hospital outcome is
preserved in elderly patients undergoing coronary intervention
for anterior acute myocardial infarction. Circ J. 2005;69(6):
630–635.
Published online in Wiley InterScience. (www.interscience.wiley.com)
27. Mehta SR, Cannon CP, Fox KA, et al. Routine vs selective strategies
in patients with acute coronary syndromes: a collaborative meta-
analysis of randomised trials. JAMA. 2005;293:2908–2917.
28. Goch A, Banach M, Piotrowski G, Szadkowska I, Goch JH.
Echocardiographic evaluation of left atrium and left atrium
appendage function in patients with atrial septum aneurysm:
implications for thromboembolic complications. Thorac Cardiovasc
Surg. 2007;55:365–370.
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