Elderly ACS Patients Receive Less Intensive Treatment, Survival Benefit Reduced

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Use of evidence-based therapies becomes incrementally less likely with increasing age in patients with acute coronary syndromes (ACS), according to a British registry study published online March 18, 2014, ahead of print in the European Heart Journal. Though intensive management is associated with better survival at all ages, the degree of benefit is diminished in older patients.

To assess the effect of secondary prevention and intensive management, M. Justin Zaman, MBBS, PhD, of James Paget University Hospital (Great Yarmouth, United Kingdom), and colleagues culled data from the Myocardial Ischaemia National Audit Project (MINAP) on 155,818 patients admitted to the hospital for STEMI (43.7%) or NSTEMI (56.3%) in England and Wales from 2006 to 2010. Patients were stratified according to whether they were aged:

• Less than 65 years (38.5%)
• 65-74 years (23.8%)
• 75-84 years (24.8%)
• More than 85 years (12.9%)

Secondary prevention included aspirin, ACE inhibitor, and statin use at discharge. Intensive management was defined for STEMI as reperfusion available locally at the time of presentation and for NSTEMI as receipt of angiography in hospital.

Interaction Seen Between Age, Treatment 

The older that patients were, the less likely they were to receive evidence-based therapies. For example, statin use at discharge was 72.4% in the oldest group and 86.9% in the youngest group (OR 0.31; 95% CI 0.29-0.33). In addition, STEMI patients aged 85 or older were less likely to receive reperfusion than those younger than 65 years (55% vs 84%; OR 0.22; 95% CI 0.21-0.24). Among NSTEMI patients, angiography was much less common in the oldest compared with the youngest cohort (14% vs 83%; OR 0.03; 95% CI 0.03-0.04).

The effect of conservative rather than intensive management on 1-year risk of death also decreased with rising age, though even the oldest group derived some benefit from more intensive care (tables 1 and 2).

Table 1. Effect of Management on Death at 1 Year: STEMI^a

^a P < 0.001 for all.

Table 2. Effect of Management on Death at 1 Year: NSTEMI^a

^a P < 0.001 for all.

According to the researchers, the diminished protection of intensive management “may be due to the higher risk of dying from ACS afforded by older age alone (as observed by around half of patients aged 85 years and over in the conservative groups dying within a year), while those youngest patients who do not undergo intensive management must have good reason not to—such as life-threatening clinical presentations or serious comorbidity—thus widening the relative benefit between intervening intensively or not.”

A ‘Clinical Conundrum’

Dr. Zaman said in an e-mail with TCTMD that the tendency toward less intensive management in elderly patients can be attributed to “a perception on the part of the clinician of a higher risk in older patients from intensive management, or that such treatments might lead to less future benefit.”

The paper acknowledges that less intensive treatment may sometimes be justified.

“What we cannot conclude from this [study] is the appropriateness for intensive management in the older patient with ACS,” the researchers note. “It is likely that clinicians are already applying clinical judgment in selecting patients for an intensive management strategy and appropriately not intensively managing those patients that are frail, or have extensive comorbidity.”

Dr. Zaman observed, “Sometimes a more invasive strategy might indeed cause more harm than good. Thus these ‘inequalities’ in care might be ‘fair inequalities.’”

In an e-mail, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), told TCTMD: “This manuscript confirms prior observations that, particularly for elderly patients with ACS, there is an unmet need for more appropriate use of evidence-based therapies. The somewhat novel finding that the incremental benefit of both medical and procedural therapies is somewhat attenuated (although notably still significant) [at higher age] crystallizes the clinical conundrum that is often faced when treating elderly patients.”

As to what factors clinicians should consider when assessing their options in this situation, Dr. Zaman said, “We don't really know. Doctors often can tell ‘from the end of the bed’ that the patient in front of them will not do well with an invasive procedure, though quantifying this subjective feeling is harder. It is probably a combination of things like patient comorbidities, frailty, cognition, and nutritional status. It may be that actual age is irrelevant—it is your ‘biological age’ that is more important (ie, how well you have looked after yourself).”

Study Details

Younger patients were more likely to be men or smokers. Prevalence of hypertension, past history of CAD, and comorbidities rose with age, while the odds of having had prior coronary revascularization decreased with age. In addition, older patients were less likely to have been cared for by a cardiologist during the index admission for ACS.

Zaman MJ, Stirling S, Shepstone L, et al. The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP). Eur Heart J. 2014;Epub ahead of print.

Disclosures:

·         The study and its Open Access publication charges were supported by the Sir Halley Stewart Trust, and MINAP is funded by the Health Quality Improvement Partnership.

·         Drs. Zaman and Kirtane report no relevant conflicts of interest.

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