TRIANA: In elderly STEMI patient, "conviction is the enemy of truth"

Late one evening, I was called to the ER to see an 84 y.o. patient with chest pain and ST elevation. Her hemoglobin was around 9.0 gm with a low MCV.  She was in severe pain, diaphoretic, and nauseated. I suspected RV involvement with unstable pressures and a quick echo confirmed my suspicions.  Since we didn’t have PCI on- site back then, (another story for another day), my only option was to transfer her for emergent care. She refused. She firmly stated she was just too old and didn’t have any family to be with her except for a distant relative. Despite pleading with her for over an hour, she dug in her heels so I transferred her up to our ICU.

She didn’t have enough blood pressure for morphine so I chose Demerol and zofran instead.  I tried to resuscitate her failing pressure with liters of IV fluid but the inevitable drop in 02 sat ensued. An increase in respiration and onset of rales heralded the end of a three-day ordeal that no human should ever have to endure.

After the TRIANA presentation, I regret even more deeply that I couldn’t convince her to undergo an emergent PCI.  Subconsciously, I’ve massaged my guilt by reasoning that her risk of renal failure might have been significant.  I was comforted that perhaps her risk of a procedurally related complication might have been too great. To this day, I am convinced that her bleeding risk would have been significant during a PCI, but we’ve ridden that one out successfully so many times that it’s not really a worthy rationale.

I do not usually allow age to bias me. I’ve cath’d three 91 year olds in the last 10 years, one of which underwent CABG and is now age 99 with several very good years beyond her procedure, but in the back of my mind, as we are going up the elevator with an octogenarian with STEMI, I subconsciously list all of the complications that could occur.   Only those with poor quality of life or terminal illness get a pass from my argument about the need for aggressive therapy.

The thought of death did not budge my patient but would the information from TRIANA have made a difference?  Would she have decided to go for aggressive therapy if I could have quoted a low incidence of renal failure?  Would she have listened if I could have given her the information that recurrent ischemia would have been profoundly reduced by a mechanical fix?

I guess I should feel less guilty since this topic is not only difficult for patients to grasp but physicians grapple with it as well.  It is equally as difficult to convince ourselves that these questions in the elderly patient with STEMI need to be definitively answered. Enrollment due to lack of enthusiasm killed the power of this trial, and also a similar trial, SENIOR PAMI, though with SENIOR PAMI the recruitment issue was the bias in favor of primary PCI. 

I heard a quote yesterday that is most appropriate for this issue, especially with regard to difficulty with recruitment for this age group: “Conviction is the enemy of truth” and the enemy of most every elderly patient in emergency rooms everywhere with ST’s up.    

Your comments

	TRIANA: In elderly STEMI patient, "conviction is the enemy of truth"
	# 1 of 2	September 1, 2009 11:57 (EDT)
	Héctor Bueno	Thanks Melissa for the report. I wish we had had that understanding by many colleagues during the trial. Your case exemplifies exactly what we tried to achieve with TRIANA, providing with evidences for a kind of patients usually excluded from RCTs. We wanted to close the gap between patients enrolled in RCTs and those we care in everyday clinical practice.
	# 2 of 2	September 2, 2009 06:41 (EDT)
	melissa	Hector, I am the one who should be thanking you for your dedication and forward thinking on this topic.  Without you and those like you, we would have never even been able to come this far.   With aging parents, whom I cherish with all of my heart, one of which has significant CAD, I will more confidently face a decision that may forever affect the amount of time that we could have together.   I thank you for my parents, my patients, and all the grandparents around the world,  from the bottom of my heart. Melissa

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