Evolution in Cardiovascular Care for Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, North Carolina 27715, USA.
Journal of the American College of Cardiology (Impact Factor: 16.5). 11/2005; 46(8):1479-87. DOI: 10.1016/j.jacc.2005.05.084
Source: PubMed


This study evaluated the impact of age on care and outcomes for non-ST-segment elevation acute coronary syndromes (NSTE ACS).
Recent clinical trials have expanded treatment options for NSTE ACS, now reflected in guidelines. Elderly patients are at highest risk, yet have previously been shown to receive less care than younger patients.
In 56,963 patients with NSTE ACS at 443 U.S. hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) National Quality Improvement Initiative from January 2001 to June 2003, we compared use of guidelines-recommended care across four age groups: <65, 65 to 74, 75 to 84, and > or =85 years. A multivariate model tested for age-related differences in treatments and outcomes after adjusting for patient, provider, and hospital factors.
Of the study population, 35% were > or =75 years old, and 11% were > or =85 years old. Use of acute anti-platelet and anti-thrombin therapy within the first 24 h decreased with age. Elderly patients were also less likely to undergo early catheterization or revascularization. Whereas use of many discharge medications was similar in young and old patients, clopidogrel and lipid-lowering therapy remained less commonly prescribed in elderly patients. In-hospital mortality and complication rates increased with advancing age, but those receiving more recommended therapies had lower mortality even after adjustment than those who did not.
Age impacts use of guidelines-recommended care for newer agents and early in-hospital care. Further improvements in outcomes for elderly patients by optimizing the safe and early use of therapies are likely.

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Available from: William E Boden, Jan 02, 2014
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    • "The wide age range has been chosen to detect differences in the discharge management of patients across different age groups and to examine the suitability of the dHMR intervention across different age groups. The former problem has been previously recognized as an area for further interventional focus by Alexander et al. in the CRUSADE trial [31] and the latter has been recognized as an area requiring further investigation through a qualitative review of the HMR service [15]. "
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    Trials 04/2012; 13:30. DOI:10.1186/1745-6215-13-30 · 1.73 Impact Factor
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    • "Also, a fear of bleeding may limit the use of antiplatelet agents, especially glycoprotein IIb–IIIa inhibitors in patients ≥75 years of age [29]. Importantly, previous studies have shown that patients who present with an acute coronary syndrome and do not receive guideline-recommended therapies, including glycoprotein IIb–IIIa inhibitors experienced higher short- and long-term mortality [30–32]. "
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    ABSTRACT: 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.
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    • "In addition, a significant decrease in the utilization rate of invasive diagnostic coronary angiography and increased in-hospital mortality were observed as patient age increased.17 Approximately 33% of all ACS episodes occur in patients over 75 years old and account for approximately 60% of overall mortality due to ACS.18–20 The incidence of ACS in the elderly is projected to increase due to advances in prior ACS treatment in an aging population.21,22 "
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