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

Duke University, Durham, North Carolina, United States
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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    ABSTRACT: Despite continual improvements in the management of acute coronary syndromes, adherence to guideline-based medications remains suboptimal. We aim to improve adherence with guideline-based therapy following acute coronary syndrome using an existing service that is provided by specifically trained pharmacists, called a Home Medicines Review. We have made two minor adjustments to target the focus of the existing service including an acute coronary syndrome specific referral letter and a training package for the pharmacists providing the service. We will be conducting a randomized controlled trial to compare the directed home medicines review service to usual care following acute coronary syndromes. All patients aged 18 to 80 years and with a working diagnosis of acute coronary syndrome, who are admitted to two public, acute care hospitals, will be screened for enrolment into the trial. Exclusion criteria will include: not being discharged home, documented cognitive decline, non-Medicare eligibility, and presence of a terminal malignancy. Randomization concealment and sequence generation will occur through a centrally-monitored computer program. Patients randomized to the control group will receive usual post-discharge care. Patients randomized to receive the intervention will be offered usual post-discharge care and a directed home medicines review at two months post-discharge. The study endpoints will be six and twelve months post-discharge. The primary outcome will be the proportion of patients who are adherent to a complete, guideline-based medication regimen. Secondary outcomes will include hospital readmission rates, length of hospital stays, changes in quality of life, smoking cessation rates, cardiac rehabilitation completion rates, and mortality. As the trial is closely based on an existing service, any improvements observed should be highly translatable into regular practice. Possible limitations to the success of the trial intervention include general practitioner approval of the intervention, general practitioner acceptance of pharmacists' recommendations, and pharmacists' ability to make appropriate recommendations. A detailed monitoring process will detect any barriers to the success of the trial. Given that poor medication persistence following acute coronary syndrome is a worldwide problem, the findings of our study may have international implications for the care of this patient group. Australian New Zealand Clinical Trials Registry ACTRN12611000452998.
    Full-text · Article · Apr 2012 · Trials
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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.
    Full-text · Article · Mar 2012 · Journal of Thrombosis and Thrombolysis
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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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    ABSTRACT: The aim of this study was to examine the trend in increasing life expectancy in relation to heart attack and cardiac catheterization. A retrospective study of very elderly patients over 90 years of age (study group) and between 70 and 79 years of age (control group) with myocardial infarction and acute coronary syndrome who underwent coronary angiography was conducted. A total of 1100 cardiac catheterizations were performed in the cardiac catheterization laboratory of Vinzentius-Hospital in Landau, Germany from 2007 to 2011. The number of coronary angiographies performed in patients aged over 90 years and those aged 70-79 years was 36 and 354, respectively, during this same time period. No increase in the number of evidence-based therapy for coronary heart disease by cardiac catheterization was observed in the very elderly patients over this time period. An increase in the number of patients aged over 90 years and a rise in heart attacks, as evaluated by coronary angiography, could not be found in this study.
    Preview · Article · Feb 2012 · Clinical Interventions in Aging
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