Guidelines for Acute Coronary Syndromes Benefit the Old Old

April 26, 2007

BOSTON -- Patients 90 or older with acute coronary syndromes have decreased hospital mortality when recommended therapy guidelines are followed, researchers have reported.

BOSTON, April 26 -- Patients 90 or older with acute coronary syndromes have decreased hospital mortality when recommended therapy guidelines are followed, according to researchers here.

So-called old-old patients who arrived at an emergency room with non-ST-segment elevation acute coronary syndromes were less likely than younger elderly patients, ages 75 to 89, to receive recommended treatments, but for those who did, survival was better, reported the CRUSADE team in the May 1 issue of the Journal of the American College of Cardiology.

The CRUSADE registry, used in this study, is an ongoing voluntary, observational quality-improvement initiative for patients with non-ST-segment elevation acute coronary syndrome, said David J. Cohen, M.D., of Beth Israel Deaconess Medical Center, and colleagues.

The researchers used the CRUSADE registry data to study 5,557 patients, age 90 and older, with acute coronary syndromes, seen in emergency rooms at 525 hospitals. Of these, 112 patients were 100 years or older. Patients were enrolled from January 2001 through June 2005.

The American College of Cardiology/American Heart Association guidelines for these patients suggest that despite the increased risks with age, the benefits of aggressive treatment and prompt revascularization can be extrapolated to the older elderly from clinical trials with predominantly younger patients, the CRUSADE investigators noted.

Baseline characteristics, treatment patterns, and in-hospital outcomes among these "older elderly" were compared with treatment and outcomes for a "younger elderly" cohort of 46,270 patients, 75 to 89 years old.

Although both groups had much in common, the older elderly, compared with the younger elderly, were less likely to be diabetic, smokers, or obese, the researchers reported.

Among patients without contraindications, the older elderly were less likely to receive glycoprotein IIb/IIIa inhibitors and statins during the first 24 hours and were less likely to undergo cardiac catheterization within 48 hours, even without documented contraindications to such care, the researchers reported.

Compared with the younger elderly, the older elderly were 23% more likely to die in the hospital (12.0% vs. 7.8%, odds ratio 1.23, 95% CI, 1.13-1.35, P

There are several explanations for the underutilization of guideline-based therapies among the older elderly, the researchers wrote. These included the smaller likelihood of being cared for by a cardiologist. Under-use of antithrombotics, they said, may reflect physicians' concerns about the risk of bleeding even in patients without contraindications.

Among the study's imitations, the researchers wrote that patients in CRUSADE were enrolled only if they had chest discomfort and either ECG changes or a positive cardiac marker. As a result, many older adults with atypical symptoms or cardiac symptoms with another medical illness were excluded.

Also, key variables of functional status, cognitive status, financial considerations, for example, were not recorded. Only hospital outcomes were assessed, and further studies are needed to document longer-term functional and quality-of-life outcomes for these patients, they said.

Patients 90 and older with acute coronary syndromes were generally similar to younger elderly counterparts in terms of risk factors and underlying patient characteristics, the researchers said.

However, nonagenarians and centenarians were more likely to have documented contraindications to acute treatments, less likely to receive acute treatment independent of contraindications, and were more likely to die in the hospital than younger elderly patients. There was also a graded relationship between the number of therapies delivered and bleeding complications.

Nonetheless, the researchers noted that increasing adherence to guideline-recommended therapies was associated with lower hospital mortality in both cohorts.

These findings reinforce the importance of optimizing care patterns for even the oldest patients with acute coronary syndromes while examining novel approaches to reduce the risk of bleeding for this rapidly expanding patient population, the investigators concluded.