Do patients with ACS aged 90 years or older receive the same standard of care as younger patients?

BACKGROUND In the US,. around 30% of deaths from myocardial infarction occur in patients aged over 85 years, but individuals in this age group are often excluded from clinical trials. Thus, there are uncertainties about the optimum management of elderly patients with cardiac disease and their suitability for therapies that have been developed in younger individuals. OBJECTIVE To compare the baseline characteristics, treatment, and outcomes of 'older elderly' (aged ≥90 years) and 'younger elderly' (aged 75-89 years) patients with non-ST-segment elevation acute coronary syndromes (non-STE ACS). DESIGN The cohort for this retrospective, observational study was derived from the CRUSADE National Quality Improvement Initiative, which is an ongoing registry of patients admitted to hospital with non-STE ACS within 24h of symptom onset. All participants have elevated cardiac biomarkers, transient ST-segment elevation, ST-segment depression, or another high-risk characteristic for non-STE ACS. The patients included in this analysis were aged 75 years or older and registered in the CRUSADE database between 1 January 2001 and 30 June 2005. OUTCOME MEASURES The outcome measures were in-hospital mortality and in-hospital adverse events. RESULTS This analysis included 51,827 patients--46,270 in the 'younger elderly' group and 5,557 in the 'older elderly' group. There were more female patients in the older than in the younger age-group (67.4% vs 50.1%). 'Older elderly' patients had a lower incidence of traditional coronary risk factors, higher levels of HDL cholesterol, and were less likely to have undergone a previous coronary intervention or to have been cared for by a cardiologist than were those in the younger group. 'Older elderly' patients had more contraindications to guideline-based therapies than did their younger counterparts. Contraindications to cardiac catheterization were cited as being 'advanced age' in 40.6% of patients and 'do-not-resuscitate' status in 29.3%. Nevertheless, even in the absence of contraindications, 'older elderly' patients were less likely to receive guideline-based therapies than the 'younger elderly' (clopidogrel 35.5% vs 40.1%; statins 30.4% vs 45.7%; glycoprotein IIb/IIIa inhibitors 12.0% vs 29.2%; percutaneous coronary intervention 6.5% vs 20.2%; CABG surgery 1.1 % vs 9.4%; P<0.001 for all). Patients in the older age-group were more likely to die or experience adverse cardiac outcomes while in hospital than were younger patients (12.0% vs 7.8% and 26.8% vs 21.3%, respectively; P<0.001 for both). In both groups, adherence to guidelinebased therapies was associated with decreased mortality (P<0.001 for trend). Treatment with cardiac catheterization within 48h of hospital admission (odds ratio [OR] 0.70), β-blockers (OR 0.67), and aspirin (OR 0.65) produced the most pronounced reductions in mortality. CONCLUSIONS Patients with non-STE ACS aged 90 years or older are more likely to die or suffer adverse cardiac events in hospital and less likely to receive guideline-based therapies than are younger patients. Adherence to therapy in the older elderly is, however, associated with lower mortality. [ABSTRACT FROM AUTHOR]