Comparison of Outcomes in Patients Aged <75, 75 to 84, and ≥85 Years With ST-Elevation Myocardial Infarction (from the ACTION Registry-GWTG)

doi:10.1016/j.amjcard.2010.07.008

The American Journal of Cardiology

Volume 106, Issue 10, 15 November 2010, Pages 1382-1388

https://doi.org/10.1016/j.amjcard.2010.07.008 Get rights and content

ST-segment elevation myocardial infarction (STEMI) is common in older adults and has high age-related mortality. We describe contemporary STEMI care using the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Network Registry–Get With The Guidelines (ACTION-GWTG) database. Patients with STEMI (n = 30,188) from 285 ACTION-GWTG sites from January 1, 2007 to June 30, 2008 were grouped by age (<75, 75 to 84, and ≥85 years) to compare baseline characteristics, reperfusion, and in-hospital outcomes. In this population, 79.7% (24,070) were <75 years old, 14.2% (4,273) were 75 to 84 years old, and 6.1% (1,845) were ≥85 years old (the oldest old). Compared to younger patients, the oldest-old patients (median age 88 years, interquartile range 86 to 91) were more often women, had more hypertension, and end-organ co-morbidity (heart failure and stroke, p <0.0001 for all). More than 42% of the oldest old were also cited as having contraindications to reperfusion, but with absolute or relative contraindications noted in only 10%, and patient preference was the most common reason indicated (45%). Even in reperfusion-eligible patients, the oldest old were less likely to receive it. Although patients who received reperfusion had better outcomes than those who did not, this was significant only for younger patients (<75 years old, odds ratio 0.58, confidence interval 0.40 to 0.84). In conclusion, >42% of the oldest old have reported contraindications to reperfusion, with neither mortality benefit nor harm in those who receive it. Disparities in process of care and co-morbidity may explain these observational findings. Whether efforts to optimize patient selection and initiate reperfusion therapy can improve outcomes in the oldest old with STEMI is unknown.

Section snippets

Methods

The ACTION-GWTG is part of the National Cardiovascular Data Registry and was created to evaluate and improve the quality of MI care.¹⁵ Participating ACTION-GWTG hospitals enroll consecutive patients with a primary diagnosis of STEMI or non-STEMI. At most hospitals, patients are retrospectively identified and are deemed ineligible if admitted for conditions unrelated to MI. In all instances, patient care decisions are the responsibility of the treating physicians. Criteria for patients with

Results

Of the 30,188 patients with STEMI selected, 79.7% (24,070) were <75 years old, 14.2% (4,273) were 75 to 84 years old, and 6.1% (1,845) were ≥85 years old (e.g., the oldest old). The oldest-old patients were mostly women, were not recent smokers, and had less diabetes mellitus and hyperlipidemia. This group had higher prevalence of end-organ co-morbidity (previous heart failure and stroke; Table 1). They also had lower creatinine clearance and higher B-type natriuretic peptide levels than the

Discussion

The oldest-old population comprises about 6% of the STEMI population. This special group has a fourfold higher in-hospital mortality compared to younger patients, a hazard that persists after adjustment and irrespective of reperfusion status. Our data further demonstrate that 42% of the oldest old have contraindications to the reperfusion cited, with patient preference being the primary factor determining this designation. Furthermore, even when the oldest old are deemed eligible for

References (30)

R.S. Stafford et al.
The underutilization of cardiac medications of proven benefit, 1990–2002
J Am Coll Cardiol
(2003)
L. Mallet et al.
The challenge of managing drug interactions in elderly people
Lancet
(2007)
D.R. Holmes et al.
Effect of age on outcome with primary angioplasty versus thrombolysis
J Am Coll Cardiol
(1999)
K.A. Eagle et al.
Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE)
Lancet
(2002)
M.J. de Boer et al.
Reperfusion therapy in elderly patients with acute myocardial infarction: a randomized comparison of primary angioplasty and thrombolytic therapy
J Am Coll Cardiol
(2002)
M. Martínez-Sellés et al.
Influence of reperfusion therapy on prognosis in patients aged > or =89 years with acute myocardial infarction
Am J Cardiol
(2005)
V.S. DeGeare et al.
Angiographic and clinical characteristics associated with increased in-hospital mortality in elderly patients with acute myocardial infarction undergoing percutaneous intervention (a pooled analysis of the primary angioplasty in myocardial infarction trials)
Am J Cardiol
(2000)
H.H. Ting et al.
Delay in presentation and reperfusion therapy in ST-elevation myocardial infarction
Am J Med
(2008)
P. Shah et al.
Outcomes and quality of life in patients > or =85 years of age with ST-elevation myocardial infarction
Am J Cardiol
(2009)
H.M. Krumholz et al.
ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on performance measures (writing committee to develop performance measures for ST-elevation and non-ST-elevation myocardial infarction): developed in collaboration with the American Academy of Family Physicians and the American College of emergency physicians: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, Society for Cardiovascular Angiography and Interventions, and society of Hospital Medicine
Circulation
(2008)

E.M. Antman et al.

2007 Focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee

Circulation

(2008)

E.M. Antman et al.

ACC/AHA guidelines for the management of patients with ST elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)

Circulation

(2004)

K.P. Alexander et al.

Acute coronary care in the elderly (part II) ST segment elevation myocardial infarctionA scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology

Circulation

(2007)

K.A. Eagle et al.

Global Registry of Acute Coronary Events (GRACE) InvestigatorsTrends in acute reperfusion therapy for ST-segment elevation myocardial infarction from 1999 to 2006: we are getting better but we have got a long way to go

Eur Heart J

(2008)

A.W. Schoenenberger et al.

Acute Myocardial Infarction in Switzerland Plus InvestigatorsAge-related differences in the use of guideline-recommended medical and interventional therapies for acute coronary syndromes: a cohort study

J Am Geriatr Soc

(2008)

Cited by (40)

Impact of Age at the Time of the First ST-Elevation Myocardial Infarction on 10-Year Outcomes (from the EXAMINATION-EXTEND Trial)
2023, American Journal of Cardiology
The aim of this substudy of the EXAMINATION-EXTEND was to analyze 10-year outcomes according to the patient's age at the time of the first ST-elevation myocardial infarction (STEMI). Of 1,498 patients with STEMI included in the EXAMINATION-EXTEND study, those with a previous history of coronary ischemic even or ischemic stroke were excluded from this analysis. The remaining 1,375 patients were divided into 4 age groups: <55, 55 to 65, 65 to 75, and >75 years. The primary end point was 10-year patient-oriented composite end point (POCE) of all-cause death, any MI, or any revascularization. At 10-year follow-up, patients aged <55 years (adjusted hazard ratio [HR] 0.24, 95% confidence interval [CI] 0.18 to 0.31, p = 0.001), 55 to 65 years (adjusted HR 0.26, 95% CI 0.20 to 0.34, p = 0.001), and 65 to 75 years (adjusted HR 0.38, 95% CI 0.30 to 0.50, p = 0.001) showed lower risk of POCE than those aged >75 years, led by a lower incidence of all-cause death (<55 : 6% vs 55 to 65: 11.9% vs 65 to 75: 25.7% vs >75 years: 61.6%, p = 0.001). Cardiac death was more prevalent in the older group (<55: 3.7% vs 55 to 65: 5.8% vs 65 to 75: 10.9% vs >75 years: 35.5%, p = 0.001). In the landmark analyses, between 5- and 10-year follow-up, young patients exhibited a higher incidence of any revascularization (<55: 7.4% vs 55 to 65: 4.9% vs 65 to 75: 1.8% vs >65 years: 1.6%, p = 0.001). In conclusion, in patients with a first STEMI, advanced age was associated with high rates of POCE at 10-year follow-up due to all-cause and cardiac death. Conversely, younger patients exhibited a high risk of revascularization at long-term follow-up.
Demographic and Regional Trends of Mortality in Patients With Acute Myocardial Infarction in the United States, 1999 to 2019
2022, American Journal of Cardiology
Citation Excerpt :
Patients older than 85 years had pronounced decreases in AMI-related mortality in this study. These patients have a higher risk of mortality likely because of a higher burden of comorbidities and reported increased time from presentation to symptom onset.28 In addition, patients of advanced age are also more likely to present with atypical symptoms that may mask recognition of AMI and increase time to treatment, increasing mortality rate.29
Acute myocardial infarction (AMI)–related mortality has been decreasing within the United States because of improvements in management and preventive efforts; however, persistent disparities in demographic subsets such as race may exist. In this study, the nationwide trends in mortality related to AMI in adults in the United States from 1999 to 2019 are described. Trends in mortality related to AMI were assessed through a cross-sectional analysis of the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Age-adjusted mortality rates per 100,000 people and associated annual percentage change and average annual percentage changes with 95% confidence intervals (CIs) were determined. Joinpoint regression was used to assess the trends in the overall, demographic (gender, race/ethnicity, age), and regional groups. Between 1999 and 2019, a total of 3,655,274 deaths related to AMI occurred. In the overall population, age-adjusted mortality rates decreased from 134.7 (95% CI 134.2 to 135.3) in 1999 to 48.5 (95% CI 48.3 to 48.8) in 2019 with an average annual percentage change of −5.0 (95% CI −5.5 to −4.6). Higher mortality rates were seen in Black individuals, men, and those living in the South. Patients older than 85 years experienced substantial decreases in mortality. In addition, rural counties had persistently higher mortality rates in comparison with urban counties. In conclusion, despite decreasing mortality rates in all groups, persistent disparities continued to exist throughout the study period.
Acute kidney injury and in-hospital mortality in patients with ST-elevation myocardial infarction of different age groups
2021, International Journal of Cardiology
Acute kidney injury (AKI) is a well-known complication of ST-elevation acute myocardial infarction (STEMI) with an adverse impact on prognosis. Since AKI develops more frequently in elderly patients, we hypothesized that its higher incidence in older STEMI patients might explain their increased in-hospital mortality. We assessed the relationship between AKI and in-hospital mortality in patients with STEMI of different age groups.
We retrospectively evaluated 5136 STEMI patients treated with primary percutaneous coronary intervention (pPCI). We defined AKI as ≥0.5 mg/dl creatinine increase in the first 72 h. Patients were grouped according to age (<75 [n = 4040] or ≥ 75 [n = 1096] years). The primary endpoint was in-hospital mortality.
The incidence of AKI was 7%. It was 4.6% in patients <75 years and 15.1% in those ≥75 years (P < 0.0001). The overall in-hospital mortality was 4%. It was 2.6% and 8.5% in patients younger and older than 75 years, respectively (P < 0.0001). It was higher in AKI than in non-AKI patients, both in the overall population (27% vs. 2%) and in the two age groups (25% vs. 2% and 29% vs. 5% in younger and older patients, respectively; P < 0.0001). The adjusted odds ratio of in-hospital mortality associated with AKI progressively decreased in parallel with increasing age decades (from 24.7 [95% CI 11.2–54.1] in patients <65 years to 3.9 [95% CI 1.6–9.7] in those >85 years).
In STEMI patients treated with pPCI, AKI incidence and in-hospital mortality steadily increase with age. However, the prognostic impact of AKI is progressively reduced as age increases.
Presentation, Treatment, and Outcomes of the Oldest-Old Patients with Acute Myocardial Infarction: The SILVER-AMI Study
2021, American Journal of Medicine
Citation Excerpt :
No previous study has provided such a comprehensive evaluation of the oldest-old population with myocardial infarction, particularly in regards to several age-related conditions and functional impairments. The sparse literature that focuses on the oldest-old includes studies that are either claims based,5,6 retrospective,3,7 or focused on none or only some of these functional measures.4,8,30,31 Understanding the heterogeneity in presentation, treatment, and outcomes after myocardial infarction necessitates examining a wide range of these health indicators in this vulnerable population.
Oldest-old patients (≥85 years) constitute half the acute myocardial infarction hospitalizations among older adults and more commonly have atypical presentation, under-treatment, and functional impairments. Yet this group has not been well characterized. We characterized differences in presentation, functional impairments, treatments, health status, and mortality among middle-old (75–84 years) and oldest-old patients with myocardial infarction.
We analyzed data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study that enrolled 3041 patients ≥75 years of age from 94 hospitals across the US between 2013 and 2016. We performed Cox proportional hazards regression to examine the association between the oldest-old (n = 831) and middle-old (n = 2210) age categories with postdischarge 6-month case fatality rate adjusting for sociodemographic and clinical variables, and mobility impairment.
The oldest-old were less likely to present with chest pain (52.7% vs 57.7%) as their primary symptom or to receive coronary revascularization (58.1% vs 71.8) (P < .01 for both). The oldest-old were more likely to have functional impairments and had higher 6-month mortality compared with the middle-old patients (hazard ratio 1.78, 95% confidence interval, 1.39-2.28). This association was substantially attenuated after adjusting for mobility impairment (hazard ratio 1.29, confidence interval, 0.99-1.68).
There is considerable heterogeneity in presentation, treatment, and outcomes among older patients with myocardial infarction. Mobility impairment, a marker for frailty, modifies the association between advanced age and treatments as well as outcomes.
Trends in management and outcome of acute coronary syndrome in women ≥80 years versus those <80 years in Israel from 2000–2016
2019, International Journal of Cardiology
While women ≥80 years old have a high prevalence of coronary artery disease (CAD), little data exist regarding their outcome following acute coronary syndrome (ACS).
In a retrospective study based on data of 3518 ACS women patients who were enrolled in the ACS Israel Survey (ACSIS), we first evaluated and compared the clinical outcomes of 858 ACS women ≥80 years with 2660 ACS women <80 years, hospitalized during 2000–2016. Secondly, we evaluated the clinical outcome of 450 women ≥80 years hospitalized during 2000–2006 (‘early period’) and compared them with 408 ACS women of the same age group hospitalized during 2008–2016 (‘late period’).
Implementation of the ACS AHA/ACC/ESC therapeutic guidelines was lower in ACS women ≥80 years compared with women <80 years. Multivariate Cox regression analysis demonstrated a worse 1-year survival rate in the ACS women ≥80 years compared with those <80 years. During the late period women ≥80 years were treated more frequently with guideline-recommended therapies compared with patients from the same age group who were hospitalized in the early period. A significant decline in in-hospital mortality rates in ACS women ≥80 years hospitalized in the late compared with the early period was demonstrated. However, 7-day, 30-day and 1-year mortality rates were not significantly changed.
Adverse outcome rates of ACS women ≥80 years were significantly higher compared with those <80 years. In-hospital survival rates of ACS women patients ≥80 years improved during the 2000–2016 period; however, long-term survival rates were not significantly changed.
Trends and Impact of Door-to-Balloon Time on Clinical Outcomes in Patients Aged <75, 75 to 84, and ≥85 Years With ST-Elevation Myocardial Infarction
2017, American Journal of Cardiology
Citation Excerpt :
They also have higher rates of cognitive and functional impairment.14 Consequently, a decision on whether to undertake primary PCI is more complicated and most likely explains the lower rates of reperfusion in elderly patients with STEMI.7,14 In our selected cohort of patients who underwent primary PCI, procedural success was statistically lower in the elderly (93.4%) and very elderly (94.6%).
Guidelines strongly recommend patients with ST-elevation myocardial infarction (STEMI) receive timely mechanical reperfusion, defined as door-to-balloon time (DTBT) ≤90 minutes. The impact of timely reperfusion on clinical outcomes in patients aged 75–84 and ≥85 years is uncertain. We analysed 2,972 consecutive STEMI patients who underwent primary percutaneous coronary intervention from the Melbourne Interventional Group Registry (2005–2014). Patients aged <75 years were included in the younger group, those aged 75–84 years were in the elderly group and those ≥85 years were in the very elderly group. The primary endpoints were 12-month mortality and major adverse cardiovascular events (MACE). 2,307 (77.6%) patients were <75 years (mean age 59 ± 9 years), 495 (16.7%) were 75–84 years and 170 (5.7%) were ≥85 years. There has been a significant decrease in DTBT over 10 years in younger and elderly patients (p-for-trend <0.01 and 0.03) with a trend in the very elderly (p-for-trend 0.08). Compared to younger and elderly patients, the very elderly had higher 12-month mortality (3.6% vs 10.7% vs. 29.4%; p = 0.001) and MACE (10.8% vs 20.6% vs 33.5%; p = 0.001). DTBT ≤90 minutes was associated with improved outcomes on univariate analysis but was not an independent predictor of improved 12-month mortality (OR 0.84, 95% CI 0.54–1.31) or MACE (OR 0.89, 95% CI 0.67–1.16). In conclusion, over a 10-year period, there was an improvement in DTBT in patients aged <75 years and 75–84 years however DTBT ≤90 minutes was not an independent predictor of 12-month outcomes. Thus assessing whether patients aged ≥85 years are suitable for invasive management does not necessarily translate to worse clinical outcomes.

View all citing articles on Scopus

: The ACTION Registry-GWTG is a program of the National Cardiovascular Data Registry with support from the American College of Cardiology and the American Heart Association that receives funding by the Schering-Plough Corporation, Whitehouse Station, New Jersey, and Bristol-Myers Squibb/Sanofi Pharmaceutical Partnership, New York, New York.

View full text

Coronary artery diseaseComparison of Outcomes in Patients Aged <75, 75 to 84, and ≥85 Years With ST-Elevation Myocardial Infarction (from the ACTION Registry-GWTG)

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Med

Am J Cardiol

Circulation

Circulation

Circulation

Acute coronary care in the elderly (part II) ST segment elevation myocardial infarctionA scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology

Circulation

Global Registry of Acute Coronary Events (GRACE) InvestigatorsTrends in acute reperfusion therapy for ST-segment elevation myocardial infarction from 1999 to 2006: we are getting better but we have got a long way to go

Eur Heart J

Acute Myocardial Infarction in Switzerland Plus InvestigatorsAge-related differences in the use of guideline-recommended medical and interventional therapies for acute coronary syndromes: a cohort study

J Am Geriatr Soc

Coronary artery disease
Comparison of Outcomes in Patients Aged <75, 75 to 84, and ≥85 Years With ST-Elevation Myocardial Infarction (from the ACTION Registry-GWTG)