Non-st–elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome

doi:10.1016/j.ahj.2003.12.016

American Heart Journal

Volume 147, Issue 5, May 2004, Pages 830-836

https://doi.org/10.1016/j.ahj.2003.12.016 Get rights and content

Abstract

Background

The purpose of this study was to assess the current care of elderly patients with non-ST–elevation acute coronary syndrome (ACS), with particular regard to the rate of use of antiplatelet drugs and the type of strategy, aggressive or conservative, in a population of consecutive patients admitted to 76 Coronary Care Units in Italy.

Methods

Prospective registry of patients admitted to Coronary Care Units with a diagnosis of non-ST–elevation ACS during a 2-month period. Thirty-day follow-up was available in all patients.

Results

Of 1581 patients enrolled in the registry, 564 were 75 years or older. As compared with the 1017 younger patients, elderly patients had a greater prevalence of female sex (42% vs 27%, P < .001), hypertension (70% vs 59%, P < .001), prior myocardial infarction (MI) (41% vs 29%, P < .001), prior angina (18% vs 13%, P < .01), prior use of aspirin (49% vs 39%, P < .001), ST-segment depression (54% vs 43%, P < .001), and troponin positivity (66% vs 59%, P < .05). The higher-risk profile of elderly patients was confirmed by the greater number of patients with a high TIMI risk score (37% vs 22%, P < .001). GPIIb/IIIa inhibitors were less frequently used in elderly patients (P < .05). An aggressive strategy (coronary arteriography within 4 days of admission, followed by revascularization, if feasible) was adopted in 39% elderly patients and in 56% younger patients (P < .001). An interventional procedure within 30 days was performed in 30% of elderly patients and 48% of younger patients (P < .001). Elderly patients had a more unfavorable 30-day outcome compared with younger ones, as shown by the higher rates of death (6.4% vs 1.7%), acute myocardial infarction (7.1% vs 5%), and stroke (1.3% vs 0.5%). Multivariate analysis of the elderly group identified a conservative strategy (OR, 2.31; 95% CI, 1.20 to 4.48) and a diagnosis of non–Q-wave MI (OR, 2.27; 95% CI, 1.32 to 3.93) as independent predictors of 30-day events.

Conclusions

The elderly represent a very high-risk subgroup among patients with non-ST–elevation ACS, with a nearly 4-fold as high 30-day death rate as that of younger patients. These data call for a greater attention to such population, both in terms of an improved representation in clinical research and of the assessment of the outcome of different strategies in appropriately designed randomized trials.

Section snippets

Methods

The ROSAI-2 Study Group consisted of 76 Coronary Care Units (CCUs) in 7 regions of Northern and Central Italy, including Lombardia, Veneto, Trentino-Alto Adige, Piemonte, Liguria, Emilia-Romagna, and Toscana. Selected hospitals within each region were identified to give a representative assessment of local practice patterns among hospitals with a CCU without a Catheterization Laboratory (Cath Lab) (38 hospitals) and hospitals with a CCU and an interventional Cath Lab (38 hospitals).

Clinical, ECG findings, and treatment strategy

Of the 1581 patients with a confirmed diagnosis of non-ST–elevation ACS enrolled in the registry, 564 (31%) were 75 years or older. These elderly patients had more frequently hypertension, female sex, chronic angina, previous MI, and prior use of aspirin than younger patients (Table I). The greater risk profile of elderly patients was confirmed by the larger number of patients presenting with ST-segment depression and a high TIMI risk score. Serum troponin levels were measured in 1089 patients

Discussion

The results of this registry confirm that elderly patients represent a high-risk subset among patients admitted to the CCU with non-ST–elevation acute coronary syndrome. The TIMI risk score,¹² which reflects the clinical profile of patients with unstable angina/non–Q-wave MI, was found to be high in 36.7% of elderly patients as compared with 22.2% of younger patients. Moreover, coronary arteriography, as expected, revealed a greater extent of coronary artery disease and a higher percentage of

Acknowledgements

We thank Eli Lilly Italia for its financial and logistic support and Dr Mario Pedrani for helpful assistance.

References (23)

C.N. Shahi et al.
Quality of care among elderly patients hospitalized with unstable angina
Am Heart J
(2001)
H.V. Anderson et al.
Management of unstable angina pectoris and non-Q-wave acute myocardial infarction in the United States and Canada (the TIMI III Registry)
Am J Cardiol
(1997)
J.C. Munoz et al.
Coronary stent implantation in patients older than 75 years of ageclinical profile and initial and long-term (3 years) outcome
Am Heart J
(2002)
R.C. Thompson et al.
Changing outcome of angioplasty in the elderly
J Am Coll Cardiol
(1996)
J. Lindsay et al.
Morbidity and mortality rates in elderly patients undergoing percutaneous coronary transluminal angioplasty
Am Heart J
(1994)
R.E. Shaw et al.
Development of a risk adjustment mortality model using the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) experience1998–2000
J Am Coll Cardiol
(2002)
D.A. Morrison et al.
Coronary angioplasty for elderly patients with “high risk” unstable anginashort term outcomes and long-term survival
J Am Coll Cardiol
(1997)
M. Feinleib et al.
Coronary heart disease and related proceduresnational hospital discharge survey data
Circulation
(1989)
H. Hirsh et al.
Percutaneous revascularization for unstable angina in the elderly
Coron Artery Dis
(2000)
C.P. Cannon
Elderly patients with acute coronary syndromeshigher risk and greater benefit from antithrombotic and interventional therapies
Am J Geriatr Cardiol
(2000)

M.R. Patel et al.

Pharmacological treatment of elderly patients with acute coronary syndromes without persistent ST segment elevation

Drugs Aging

(2002)

Cited by (76)

Invasive management of acute coronary syndrome: Interaction with competing risks
2018, International Journal of Cardiology
The aim of this study was to characterise the interaction between ACS- and non-ACS-risk on the benefits of invasive management in patients presenting with acute coronary syndrome (ACS).
Consecutive patients admitted to a tertiary hospital's Cardiac Care Unit in the months of July–December, 2003–2011 with troponin elevation (>30 ng/L) were included. “ACS-specific-risk” was estimated using the GRACE score and “non-ACS-risk” was estimated using the Charlson-Comorbidity-Index (CCI). Inverse-probability-of-treatment weighting was used to adjust for baseline differences between patients who did or did not receive invasive management. A multivariable flexible parametric model was used to characterise the time-varying hazard.
In total, 3057 patients were included with a median follow-up of 9.0 years. Based on CCI, 1783 patients were classified as ‘low-non-ACS risk’ (CCI ≤ 1; invasive management 81%; 12-month mortality 5%), 820 as ‘medium-non-ACS risk’ (CCI 2–3; invasive management 68%; 12-month mortality 13%), and 468 as ‘high-non-ACS risk’ (CCI ≥ 4; invasive management 47%; 12-month mortality 29%). After adjustment, invasive management was associated with a significant reduction in one-year overall-mortality in the ‘low-risk’ and ‘medium-risk’ groups (HR = 0.38, 95%CI:0.26–0.56; HR = 0.46, 95%CI:0.32–0.67); but not in the ‘high-risk’ group (HR = 1.02, 95%CI:0.67–1.56). The absolute benefit of invasive management was greatest with higher baseline ACS-risk, with a non-linear interaction between ACS- and non-ACS-risk.
There is a complex interaction between ACS- and non-ACS-risk on the benefit of invasive management. These results highlight the need to develop robust methods to objectively quantify risk attributable to non-ACS comorbidities in order to make informed decisions regarding the use of invasive management in individuals with numerous comorbidities.
Acute Myocardial Infarction Population Incidence and Mortality Rates, and 28-day Case-fatality in Older Adults. The REGICOR Study
2018, Revista Espanola de Cardiologia
Los objetivos son determinar las tasas de incidencia y mortalidad, y la mortalidad poblacional y hospitalaria por infarto agudo de miocardio (IAM) de la población mayor de 74 años, la variabilidad en las características clínicas y el tratamiento de los pacientes hospitalizados, y los cambios en las tasas de incidencia y mortalidad, en la letalidad hospitalaria y en el tratamiento del IAM por grupos de edad entre 1996-1997 y 2007-2008.
Registro poblacional de IAM en Girona (Cataluña) que incluyó a pacientes con IAM mayores de 34 años.
La tasa de incidencia aumentó con la edad en varones y mujeres, respectivamente, de 169 y 28 casos/100.000/año en el grupo de 35-64 años a 2.306 y 1.384 casos/100.000/año en el de 85-94 años. La letalidad poblacional también aumentó con la edad, del 19% en el grupo de 35-64 años al 84% en el de 85-94 años. Se observó un descenso en la letalidad poblacional en el segundo periodo analizado, explicado por un descenso en la letalidad hospitalaria. El uso de procedimientos invasivos y fármacos de eficacia demostrada disminuyó con la edad, aunque aumentó en el segundo periodo en todos los grupos de edad hasta los 84 años.
La incidencia, la mortalidad y la letalidad hospitalaria del IAM aumentaron exponencialmente con la edad. Todavía se observan diferencias en el uso de procedimientos invasivos y fármacos de eficacia demostrada entre grupos de edad.
Our aims were to determine acute myocardial infarction (AMI) incidence and mortality rates, and population and in-hospital case-fatality in the population older than 74 years; variability in clinical characteristics and AMI management of hospitalized patients, and changes in the incidence and mortality rates, case-fatality, and management by age groups from 1996 to 1997 and 2007 to 2008.
A population-based AMI registry in Girona (Catalonia, Spain) including individuals with suspected AMI older than 34 years.
The incidence rate increased with age from 169 and 28 cases/100 000 per year in the group aged 35 to 64 years to 2306 and 1384 cases/100 000 per year in the group aged 85 to 94 years, in men and women, respectively. Population case-fatality also increased with age, from 19% in the group aged 35 to 64 years to 84% in the group aged 85 to 94 years. A lower population case-fatality was observed in the second period, mainly explained by a lower in-hospital case-fatality. The use of invasive procedures and effective drugs decreased with age but increased in the second period in all ages up to 84 years.
Acute myocardial infarction incidence, mortality, and case-fatality increased exponentially with age. There is still a gap in the use of invasive procedures and effective drugs between younger and older patients.
Full English text available from: www.revespcardiol.org/en
Early Invasive Versus Initially Conservative Strategy in Elderly Patients Older Than 75 Years with Non-ST-Elevation Acute Coronary Syndrome: A Meta-Analysis
2018, Heart Lung and Circulation
Fear of complications related to the procedure and unclear benefits in elderly patients are common reasons for invasive angiography being withheld.
We searched PubMed and Embase from inception until February 2016 for studies that enrolled individuals older than 75 years with non-ST-elevation acute coronary syndrome (NSTE-ACS) and allocated patients to either an invasive or conservative strategy.
Thirteen studies (four randomised controlled trials (RCTs) and nine observational studies) enrolling 832,007 elderly NSTE-ACS patients were analysed. Compared with the conservative treatment, the early invasive approach does significantly reduce the risk of death at follow-up from 6 months to 5 years (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.59–0.73, p < 0.001); the definite benefit was mainly observed in observational studies (RR 0.63, 95% CI 0.57–0.70, p < 0.001), and the risk of death also showed a strong trend toward reduction with invasive approach (RR 0.82, 95% CI 0.64–1.05, p = 0.119) in RCTs. For the outcome of bleeding complications, there was a higher risk of any bleeding occurring in-hospital (RR 2.51, 95% CI 1.53–4.11, p < 0.001) in patients treated with invasive strategy than those treated with conservative strategy. However, no difference of in-hospital major bleeding (RR 1.78, 95% CI 0.31–10.13, p = 0.514) was observed between the two strategies.
Elderly patients with NSTE-ACS might benefit from an early invasive strategy but with increasing risk of any bleeding complications. More RCTs are needed to assess early invasive strategies in the elderly.
MANAGEMENT OF ACUTE CORONARY SYNDROME IN THE ELDERLY
2017, Revista Medica Clinica Las Condes
La Cardiopatía Coronaria y una de sus expresiones clínicas más frecuentes, el Síndrome Coronario Agudo (SCA), con o sin elevación ST, son una de las principales causa de mortalidad en nuestro medio. Los adultos mayores (AM), con el aumento de las expectativas de vida representan un segmento cada vez mas importante de la población, que habitualmente tiene un mayor riesgo de sufrir un SCA. El mejor control de los factores de riesgo cardiovascular, así como el avance en el diagnóstico y el tratamiento de la enfermedad coronaria, ha provocado un aumento del número de personas mayores en riesgo de sufrir un SCA, pese a ello, el AM y sobre todo, el muy anciano, no están debidamente representados en los ensayos clínicos. La bases de la terapia están sustentadas en numerosos estudios clínicos controlados, los cuales frecuentemente ingresan pacientes más jóvenes, con menos comorbilidad, por lo cual sus conclusiones no necesariamente se aplican al adulto mayor. Por otro lado, casi la mitad de los SCA se da en pacientes adultos mayores, que tienen peor evolución clínica y una evidente mayor mortalidad. El diagnóstico es más complejo por la menor frecuencia de dolor, alteraciones electrocardiográficas basales más frecuentes y la presencia de comorbilidad y fragilidad. La terapia actual de los SCA se basa en la anti-agregación plaquetaria dual y anticoagulación con el riesgo evidente de sangrado en el adulto mayor. Se debe definir una estrategia para el diagnóstico y manejo precoz del SCA en el AM, la que debe ser individualizada para la condición general del paciente.
Acute Coronary Syndrome (ACS), with or without ST-Segment elevation, is most common clinical expressions of Coronary Heart Disease, and one of the main causes of mortality in our country. The Elderly with increasing life expectancy, represent an increasingly important segment of the population, which usually has a higher risk of suffering from an ACS. Better control of cardiovascular risk factors, as well as progress in the diagnosis and treatment of coronary heart disease, has led to an increase in the number of elderly persons at risk for ACS, and are not properly represented in clinical trials. The basics of therapy are set in numerous controlled clinical studies, with more younger patients with less comorbidity, so their conclusions do not necessarily apply to the elderly. On the other hand, almost half of ACS occur in elderly patients, which has a worse clinical course and an evident higher mortality. The diagnosis is more complex due to the lower frequency of pain, more frequent baseline electrocardiographic alterations, and the presence of comorbidity and frailty Current. ACS therapy is based on dual platelet anti-aggregation and anticoagulation with the obvious risk of bleeding in the elderlyt. A strategy for the diagnosis and early management of ACS should be defined in the elderly, which should be individualized for the general condition of the patient
Randomized comparison between the invasive and conservative strategies in comorbid elderly patients with non-ST elevation myocardial infarction
2016, European Journal of Internal Medicine
Citation Excerpt :
Furthermore, these patients are underrepresented in clinical trials. Previous registries of non-STEMI suggest that an invasive strategy might also provide benefit to elderly patients [18], being safe and feasible even in patients over 90 years [19]. In a very large registry of octogenarians with non-STEMI, the early invasive management was associated with lower in-hospital mortality [20].
Comorbid elderly patients with non-ST-elevation myocardial infarction (non-STEMI) are underrepresented in randomized trials and undergo fewer cardiac catheterizations according to registries. Our aim was to compare the conservative and invasive strategies in these patients.
Randomized multicenter study, including 106 patients (January 2012–March 2014) with non-STEMI, over 70 years and with comorbidities defined by at least two of the following: peripheral artery disease, cerebral vascular disease, dementia, chronic pulmonary disease, chronic renal failure or anemia. Patients were randomized to invasive (routine coronary angiogram, n = 52) or conservative (coronary angiogram only if recurrent ischemia or heart failure, n = 54) strategy. Medical treatment was identical. The main endpoint was the composite of all-cause mortality, reinfarction and readmission for cardiac cause (postdischarge revascularization or heart failure), at long-term (2.5-year follow-up). Analysis of cumulative event rate (incidence rate ratio = IRR) and time to first event (hazard ratio = HR), were performed.
Cardiac catheterization/revascularization rates were 100%/58% in the invasive versus 20%/9% in the conservative arm. There were no differences between groups in the main endpoint (invasive vs conservative: IRR = 0.946, 95% CI 0.466–1.918, p = 0.877) at long-term. The invasive strategy, however, tended to improve 3-month outcomes in terms of mortality (HR = 0.348, 95% CI 0.122–0.991, p = 0.048), and of mortality or ischemic events (reinfarction or postdischarge revascularization) (HR = 0.432, 95% CI 0.190–0.984, p = 0.046). This benefit declined during follow-up.
Invasive management did not modify long-term outcome in comorbid elderly patients with non-STEMI. The finding of a tendency towards an improvement in the short-term needs confirmation in larger studies (clinicaltrials.govNCT1645943).
Administration of low molecular weight and unfractionated heparin during percutaneous coronary intervention
2016, Indian Heart Journal
This systematic review with meta-analysis sought to determine the efficacy and safety of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) on clinical outcomes following percutaneous coronary intervention. Medline, Embase, Elsevier, and web of knowledge as well as Google scholar literature were used for selecting appropriate studies with randomized controlled design. After screening 445 studies, a total of 23 trials (including a total of 43,912 patients) were identified that reported outcomes. Pooled analysis revealed that LMWH compared to UFH could significantly increase thrombolysis in myocardial infarction grade 3 flow (p < 0.001), which was associated with similar target vessel revascularization (p = 0.6), similar incidence of stroke (p = 0.7), and significantly lower incidence of re-myocardial infarction (p < 0.001), major bleeding (p = 0.02) and mortality (p < 0.001). Overall, LMWH was shown to be a useful type of heparin for patients with MI undergoing PCI, due to its higher efficacy and lower rate of complication compared to UFH. It is also associated with increased myocardial perfusion, decreased major hemorrhage, and mortality.

View all citing articles on Scopus

View full text

Clinical investigations: acute ischemic heart diseaseNon-st–elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Clinical, ECG findings, and treatment strategy

Discussion

Acknowledgements

Am Heart J

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Coronary heart disease and related proceduresnational hospital discharge survey data

Circulation

Percutaneous revascularization for unstable angina in the elderly

Coron Artery Dis

Elderly patients with acute coronary syndromeshigher risk and greater benefit from antithrombotic and interventional therapies

Am J Geriatr Cardiol

Pharmacological treatment of elderly patients with acute coronary syndromes without persistent ST segment elevation

Drugs Aging

Clinical investigations: acute ischemic heart disease
Non-st–elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome