EHJ: Elderly less likely to receive proper evidence-based angiographic treatment

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Evidence-based management, particularly with angiography, is used less frequently in elderly patients with high-risk non-ST-segment elevation acute coronary syndromes than in their younger equivalents, despite growing evidence that early revascularization reduces mortality and reinfarction rates with no significant increase in stroke, according to registry results in the May issue of the European Heart Journal.

Gerard Devlin, MD, from the department of cardiology at the Waikato Hospital in Hamilton, New Zealand, and colleagues sought to test the hypothesis that increased age in patients presenting with high-risk non-ST-segment elevation acute coronary syndromes (NSTE-ACS) does not adversely influence the benefit of an early invasive strategy on major adverse events at six months.

The researchers examined the clinical outcomes in young (less than 70), elderly (70 - 80) and very elderly (greater than 80 years) patients with high-risk NSTE-ACS enrolled in GRACE between 1999 and 2006. Six month data were available in 18,466 patients (27 percent elderly and 16 percent very elderly), the authors wrote.

The researchers said that their findings are based an analysis of data on “real-world” ACS patients from a registry covering 14 countries.

The investigators found that elderly and very elderly patients were less likely to receive evidence-based treatments at discharge and had a longer hospital stay (six versus five days). Angiography was performed more frequently in younger patients (67 vs. 33 percent in very elderly, and 55 percent in elderly), according to Devlin and colleagues.

The authors wrote that multiple logistic regression analysis confirmed the benefit of revascularization on the primary study endpoint (six-month stroke, death and MI) in young, elderly and very elderly patients.

Devlin and colleagues found that revascularization was associated with reductions in six-month mortality regardless of age; and the stroke risk in hospital or at six months was not increased by revascularization.

The authors concluded angiography, in particular, was less likely to be undertaken in the elderly. However, the researchers found that revascularization when performed was associated with significant benefits at six months, independent of age and did not increase risk of stroke.

In an accompanying editorial, Christiaan J.M. Vrints, MD, of University of Antwerp-University Hospital Antwerp in Edegem, Belgium, noted that the prevalence of older ischemic heart disease patients is rising. Vrints said that this patient population is often underrepresented in clinical trials due to age and/or comorbidities.

The result is that cardiologists may lack adequate evidence about how to manage the growing population and, in particular, how to determine which patients can benefit from an invasive approach, he noted.

Contradictorily, with increasing age and risk level, ACS patients are less likely to receive invasive treatment appears to stem from “a generalized fear” of harming elderly patients, according to Vrint.