Age-related changes in treatment strategies for acute myocardial infarction: a population-based study

Management and outcomes of ST-elevation myocardial infarction in nursing home versus community-dwelling older patients: a propensity matched study

OBJECTIVES

The influence of admission source (nursing home [NH] versus community-dwelling) on treatment strategies and outcomes among elderly patients with ST-elevation myocardial infarction (STEMI) has not been investigated.

PARTICIPANTS

Nationwide Inpatient Sample databases from 2003 to 2010 were used to identify 270,117 community-dwelling and 4082 NH patients 75 years of age or older with STEMI.

DESIGN

Retrospective observational study.

MEASUREMENTS

Propensity scores for admission source were used to assemble a matched cohort of 3081 community-dwelling and 3132 NH patients, who were balanced on baseline demographic and clinical characteristics. Bivariate logistic regression models were then used to determine the associations of NH with in-hospital outcomes among matched patients.

RESULTS

In-hospital mortality was significantly higher in patients with STEMI presenting from a NH as compared with community-dwelling patients (30.5% versus 27.6%; odds ratio [OR] 1.15, 95% confidence interval [CI] 1.03-1.29; P = .012). Overall, NH patients were less likely to receive reperfusion (thrombolysis, percutaneous coronary intervention, or coronary artery bypass grafting) (11.5% versus 13.4%; OR 0.84, 95% CI 0.72-0.98; P = .022). However, rates of percutaneous coronary intervention alone were similar in both groups (9.9% in NH versus 9.1% in community-dwelling; OR 1.10, 95% CI 0.93-1.30; P = .276). Mean length of stay was also similar in both groups (5.68 ± 5.40 days in NH versus 5.69 ± 4.98 days in community-dwelling, P = .974).

CONCLUSION

Compared with their community-dwelling counterparts, older NH patients are less likely to receive reperfusion therapy for STEMI and have higher in-hospital mortality.

Age, dementia and care patterns after admission for acute coronary syndrome: an analysis from a nationwide cohort under the National Health Insurance coverage

BACKGROUND

The number of elderly and the prevalence of dementia have grown considerably in recent years. Little is known about how aging and dementia affect care patterns after discharge for acute coronary syndrome (ACS).

OBJECTIVE

This study was designed to assess the impact of dementia on care patterns after admission for patients with ACS across different age groups.

METHODS

Of 87,321 patients hospitalized for ACS between 1 January 2006 and 31 December 2007, 1,835 patients with dementia and 3,670 matched patients without dementia (1:2 ratio, matched by age, sex and hospital level) were identified from Taiwan's National Health Insurance Research Database. Use of interventional therapies at hospitalization and guideline-recommended medications post-discharge were compared between patients with and without dementia across different age groups (≤65, 66-75, 76-85, ≥86 years). Multivariate logistic regression models were performed to examine the impact of dementia on care patterns.

RESULTS

Overall, dementia was associated with a 27% lower likelihood of receipt of interventional therapies [adjusted odds ratio (OR) = 0.73; 95% CI 0.63, 0.83] and a 22% lower likelihood of guideline-recommended medications (adjusted OR = 0.78; 95% CI 0.68, 0.89) in ACS patients. The use of interventional therapies and guideline-recommended medications decreased with age, and interactions between age and dementia were found. The proportions of patients receiving interventional therapies were 39.4% (without dementia) versus 21.8% (with dementia) in the youngest age group and 18.6% (without dementia) versus 14.5% (with dementia) in the oldest age group. Patients with dementia (age ≤65 years 73.6%; age 66-75 years 82.3%; age 76-85 years 71.8%; age ≥86 years 55.6%) were less likely to receive guideline-recommended medications as compared with those without dementia (age ≤65 years 85.6%; age 66-75 years 87.5%; age 76-85 years 81.2%; age ≥86 years 62.0%).

CONCLUSION

Dementia and aging were associated with decreased use of interventional therapies and guideline-recommended medications in ACS patients.

Left ventricular remodeling in the elderly with acute anterior myocardial infarction treated with primary coronary intervention

We compared left ventricular (LV) remodeling following a first time acute anterior ST-elevation myocardial infarction (aSTEMI) treated with primary coronary intervention (pPCI) in different age groups. A total of 116 patients, 61 aged <65 and 55 aged >or=65 years, who survived after a recent aSTEMI treated with pPCI, underwent dobutamine stress-echocardiography (DSE) and non-invasive measurement of left anterior descending coronary artery flow reserve (CFR) during intravenous adenosine infusion. Baseline LV dimensions and systolic function were similar between the two groups; wall motion score indices during all DSE stages and CFR were also similar. In both groups, the LV ejection fraction was positively affected by the presence of viability in the necrosis area and by a higher CFR, but negatively influenced by viability in a remote area, an indirect sign of an extensive infarction size. This study demonstrates that PCI in the geriatric population with aSTEMI is as equally effective as in younger subjects, in terms of LV remodeling and function.

Comparison of in-hospital secondary prevention for different vascular diseases

BACKGROUND

Secondary prevention of coronary artery disease is highly effective and implemented on a large scale. However, studies testing adherence to recommended secondary prevention of other vascular diseases are rare. Our goal was to evaluate whether the kind of vascular disease influences prescription practice of secondary drug prophylaxis at hospital discharge and to which extent secondary prevention is actually complete.

METHODS

A 3-month prospective observational review of the hospital discharge information of all patients hospitalized because of a vascular disease diagnosis: coronary artery disease (i.e. acute myocardial infarction [AMI] and chronic stable angina [CSA]); peripheral artery disease [PAD] and cerebrovascular disease [CVD]. The analysis was done by board registered internists with a structured form that founded on internationally accepted recommendations.

RESULTS

From 271 patients 191 had coronary artery disease (105 AMI and 86 CSA), 88 PAD and 72 CVD. Global prescription rate (mean; 95% CI) of indicated secondary prophylaxis drugs was 74.1% (69.9-78.2) for AMI, 72.4% (67.2-77.5) for CSA, 74.7% (68.8-80.7) for PAD and 72.1% (66.9-77.3) for CVD. The proportion of patients who were prescribed a complete bundle of recommended medications was globally 29.5% (24.1-35.0).

CONCLUSIONS

We found similar global prescription rates of secondary prevention for the different vascular diseases. However, only one third of the studied collective gets a complete set of required prophylactic drugs.

Absence of outcome difference in elderly patients with and without dementia after acute myocardial infarction

It is still unclear whether the presence of dementia has a negative effect on survival in elderly patients with acute myocardial infarction (AMI). Therefore, using data from the Tokai Acute Myocardial Infarction Study II (TAMIS-II), we set out to clarify the differences in in-hospital and long-term mortality between AMI patients with and without dementia. The study was a prospective study of all consecutive patients admitted to 15 acute care hospitals in the Tokai region with a diagnosis of AMI between 2001 and 2003. A total of 1837 patients (62 with dementia and 1775 without dementia) with AMI, aged 65 and over, were included in the present analysis. Patients with dementia were in general older, female, and impaired in their daily activities. They were also more likely to have a history of myocardial infarction, heart failure, cerebrovascular disease, and less likely to have a history of angina or smoking. They were less likely to have chest pain on arrival and lateral myocardial infarction. The percentage of patients with dementia who were transferred to an intensive care unit/coronary care unit or who were given percutaneous coronary intervention was lower. At discharge, the percentage of patients with dementia treated with aspirin was lower, and that of patients with dementia treated with diuretics was higher. In-hospital death rates for patients with and without dementia were 17.7% and 11.1% during hospitalization, respectively (P = 0.101). Long-term mortality after AMI was higher among patients with dementia before adjustment (24.2% versus 14.6%, P = 0.004). However, we were unable to detect differences after adjustment for potential confounders. Thus, our findings suggest that dementia has minimal effects on long-term mortality in patients with AMI.

Management of acute myocardial infarction in the real world: a summary report from The Ami-Florence Italian Registry

The Florence Acute Myocardial Infarction registry was a population-based, prospective study aimed at identifying the determinants of coronary reperfusion therapy [CRT, by primary coronary intervention (PCI) in more than 95% of cases] utilization and of prognosis in patients with ST-segment elevation myocardial infarction (STEMI). The registry involved one teaching hospital with, and five district hospitals without PCI facilities. Overall, as many as 45.6% of 930 cases of STEMI did not receive any form of CRT. In multivariable analysis, the direct admission to the teaching hospital was the strongest positive predictor, whereas the time delay, older age, and chronic comorbid conditions were negative predictors of CRT utilization. Compared to conservative therapy, CRT was associated with a remarkably reduced 12-month mortality, after adjusting for age, chronic comorbidities and Killip class, which also were significantly associated with long-term prognosis. The higher crude mortality observed in women was accounted for by older age and other age-related factors. The improvement in prognosis with CRT was larger in older patients and/or in those with a greater burden of chronic comorbidity, who less frequently received CRT. These results suggest the need for interdisciplinary reassessing the adherence to therapeutic guidelines and the criteria adopted in the real clinical world to select patients for CRT during STEMI.

Development and evaluation of a questionnaire for measuring patient views of involvement in myocardial infarction care

BACKGROUND

Patients' involvement in their healthcare has been associated with improved treatment outcomes in chronic illness. Less is known about the affects of patient involvement on the outcomes of acute illness, such as myocardial infarction. A better understanding of patients' views and behaviour during hospitalization might improve clinical practice and enhance patient involvement.

AIM

The aim of this study was to develop and evaluate a questionnaire for measuring patients' perceptions of their involvement during hospitalization for myocardial infarction care.

METHODS

Focus groups with myocardial infarction patients provided the basis for the construction of the questionnaire. Questionnaire validity and reliability were evaluated in a small pilot study and a larger cross-sectional study among myocardial infarction patients at eleven Swedish hospitals.

RESULTS

The questionnaire demonstrated good validity and reliability, with six factors measuring patient views and behaviour regarding involvement.

CONCLUSION

The questionnaire appears to be a useful tool for evaluating the perceptions and behaviour of patients regarding patient involvement in myocardial infarction care. Use of this questionnaire may provide insight regarding areas of patient-staff interaction that need improvement. Pinpointing such areas may lead to improved patient involvement, satisfaction with care, and treatment outcomes.

Impact of age and procedure on resource use for patients with ischemic heart disease

OBJECTIVES

Impact of age on healthcare expenditures should be assessed by targeting on specific diseases and controlling for procedures and severity of illness. Relationship between age and resource use in patients receiving acute care medicine for ischemic heart disease (IHD) was examined.

METHODS

We analyzed 19,874 IHD patients treated in 82 academic and 92 community hospitals. Length of stay (LOS), total charges (TC), and high outliers of LOS and TC were analyzed for every age group (under 65 years, 65-74 years, 75 years or older). Independent effects of age on LOS, TC, and high outliers of LOS and TC were determined using multivariate analysis.

RESULTS

7863 (39.6%) patients were under 65 years, 7181 (36.1%) between 65 years and 74 years, and 4830 (24.3%) aged 75 years or older. Proportion of angina or non-medical treatment was significantly different among three age categories (angina 72%, 75%, 71.4%; non-medical 37.3%, 40.9%, 38.9%, respectively). Significant association with LOS or TC was identified in patients receiving coronary artery bypass graft surgery with percutaneous intracoronary intervention, who were most associated with TC high outlier.

CONCLUSIONS

Age had a modest impact on resource use, as compared with procedures. Policy makers need to acknowledge the impact of procedures on healthcare spending.

Trends in management, hospital and long-term outcomes of elderly patients with acute myocardial infarction

PURPOSE

The number of elderly patients with acute myocardial infarction (AMI) is growing rapidly, and their early and postdischarge mortality is high. Several studies have reported a decline in mortality after myocardial infarction; however, the magnitude of the decline among the elderly has not been fully investigated.

METHODS

We assessed trends in management, in-hospital, and long-term outcomes of 1475 elderly patients (aged > or =75 years, 42% women) hospitalized with AMI in all 25 operating coronary care units in Israel between 1992 and 2002, from our prospective nationwide biennial surveys.

RESULTS

Between 1992 and 2002, a significant increase was observed in the use of acute reperfusion therapy (27%-48%), coronary angiography (6%-47%), percutaneous coronary intervention (3%-33%), coronary bypass (2%-8%), aspirin (53%-88%), beta-blockers (18%-65%), angiotensin-converting enzyme inhibitors (26%-63%), and lipid-lowering drugs (0%-43%). These changes were associated with a 42% reduction in 30-day mortality (27.6%-16.1%; adjusted odds ratio 0.57; 95% confidence interval [CI], 0.36-0.93). One-year cumulative mortality declined by 20% (37%-29%; adjusted odds ratio 0.74; 95% CI, 0.49-1.13).

CONCLUSIONS

The management of elderly patients with AMI changed substantially during the last decade. This change was associated with a significant reduction in early mortality, whereas cumulative 1-year mortality improved only slightly. Better adherence to in-hospital management guidelines and better implementation of postdischarge health policy may further decrease mortality and morbidity in the elderly after AMI.

Influence of diabetes mellitus on in-hospital mortality in patients with acute myocardial infarction in Japan: a report from TAMIS-II

BACKGROUND

The relation between diabetes mellitus (DM) and mortality among patients with acute myocardial infarction is still controversial. We evaluated the influence of DM on the in-hospital mortality of acute myocardial infarction (AMI) patients using data from the Tokai Acute Myocardial Infarction Study-II, a multi-hospital prospective study performed in Japan.

METHODS

All of the study subjects were patients hospitalized for newly diagnosed AMI at 1 of 13 acute care hospitals between January of 2001 and December of 2003. We abstracted the baseline and procedural characteristics from detailed chart reviews. Multivariate analysis was performed, controlling for the variables found to be significantly different between AMI patients with and without DM by chi-square test or unpaired t-test. We evaluated a total of 940 DM and 2284 non-DM patients.

RESULTS

DM patients had roughly twice the in-hospital mortality rate of non-DM patients, with an unadjusted odds ratio of 1.77 (95% CI, 1.37-2.30). However, according to the multivariate analysis, DM was not identified as an independent predictor of in-hospital death, with an adjusted odds ratio of 5.73 (95% CI, 0.97-33.88).

CONCLUSIONS

DM is not an independent predictor of in-hospital mortality, and that there is a need for additional studies to confirm our conclusion.

Age and comorbidity in acute myocardial infarction: a report from the AMI-Florence Italian registry

A total of 930 cases of ST-segment elevation myocardial infarction were prospectively recorded in the Florence health district. Factors influencing survival or those associated with use of revascularization (percutaneous coronary intervention, 91%) were identified through multivariate analyses (Cox and logistic regression, respectively). The independent protective effect of coronary reperfusion therapy (CRT) was evident at 36 months (39% reduction in the risk of death). After adjusting for all multivariate predictors, CRT use was 63% less likely at age 85 years and older than at under 65 years (p<0.001). Since beyond advancing age, comorbidity appeared to be associated with a reduced chance of CRT, three chronic comorbidity score categories were calculated using information on past medical history. Increased 1-year mortality in patients with higher comorbidity score categories derives, at least in part, from underutilization of CRT. Results confirm that although they might potentially benefit from CRT during ST-segment elevation myocardial infarction, older and frail patients are excluded from CRT, even when eligible.

Present treatment of acute myocardial infarction in patients over 75 years--data from the Berlin Myocardial Infarction Registry (BHIR)

AIMS

Guidelines issued by European and German cardiology societies clearly define procedures for treatment of acute myocardial infarction (AMI). These guidelines, however, are based on clinical studies in which older patients are underrepresented. Older patients, on the other hand, represent a large and growing portion of the infarction population. It was our goal in the present paper to analyse the present treatment of AMI patients over 75 years of age in the city of Berlin, Germany, with data gained from the Berlin Myocardial Infarction Registry (BHIR).

METHODS

We prospectively collected data from 5079 patients (3311 men and 1768 women, mean age 65.6) with acute myocardial infarction who were treated in 25 hospitals in Berlin during the period 1999-2003. 1319 patients (25.9%) were older than 75 (mean age 82.5 years).

RESULTS

Overall hospital mortality rate was 11.6%. In patients over 75, this rate was 23.9%; among the younger infarction population, it was 7.3%. In contrast to the younger AMI patients, the majority of those over 75 were female (62.5 vs 25.1% for the younger) and demonstrated a significantly higher frequency of all prognostically meaningful comorbidities (heart failure 14.4% vs. 3.5%; renal failure 11.5 vs 3.9%; diabetes 37.3 vs 24.3%). Clinical signs of severe infarction, moreover, were more common among the aged patients (pulmonary congestion 45.4 vs 19.7%; left bundle branch block 12.7 vs 3.6%). Pre-hospital time was prolonged (2.8 vs 2 h) and guideline-recommended therapy was applied significantly less frequently to AMI patients over 75 (reperfusion therapy 39.8 vs 71.7%, beta-blockers 62.8 vs 78.3%, statins 26.5 vs 45.5%). Multivariate analysis revealed the following factors to be independent predictors of hospital mortality in patients over 75: age (OR 1.05 per year), acute heart failure (OR 2.39), pre-hospital resuscitation (OR 10.6), cardiogenic shock (OR 2.73), pre-hospital delay >12 h (OR 1.68), and ST elevation in the first ECG (OR 2.09). Independent predictors of a favourable hospital course were as follows: admission to a hospital >600 beds (OR 0.64), reperfusion therapy (OR 0.63), early betablocker treatment (OR 0.46), and early application of ACE inhibitors (OR 0.48).

CONCLUSION

Infarction patients over 75 have a very high hospital complication and mortality rate. They are typically treated with delay, and with less adherence to relevant guidelines than are younger patients. Reperfusion therapy, early administration of beta-blockers and ACE inhibitors, as well as admission to large medical centres are all factors that contribute to a favourable prognosis of high-aged AMI patients.

Effect of comorbidity on coronary reperfusion strategy and long-term mortality after acute myocardial infarction

BACKGROUND

Chronic comorbidity is a prognostic determinant in ST-segment elevation myocardial infarction (STEMI). This study was aimed at determining to what extent this effect is independent or derives from adoption of different therapeutic strategies.

METHODS

Seven hundred forty patients with STEMI hospitalized within 12 hours of symptom onset were enrolled in a population-based registry, in a health district comprising 1 teaching hospital with and 5 district hospitals without percutaneous coronary intervention (PCI) facilities. Three categories of increasing chronic comorbidity score (CS-1, n = 259; CS-2, n = 235; CS-3, n = 246) were identified from age-adjusted associations of comorbidities with 1-year survival.

RESULTS

Higher CS was associated with lower direct admission or transferal rates to hospital with PCI. Coronary reperfusion therapy (PCI in 91.5% of 470 cases) was adopted less frequently (P < .001) in CS-3 (41.9%) than CS-2 (69.4%) or CS-1 (78.8%). Compared with conservative therapy (n = 270), reperfusion therapy reduced 1-year mortality in the whole series not significantly (P = .816) in CS-1 but significantly in CS-2 (P = .012) and CS-3 (P = .001). This trend persisted after adjusting for age, Killip class, and acute myocardial infarction location (hazard ratio [HR] = 0.63 [95% CI 0.14-2.80], HR = 0.62 [95% CI 0.31-1.25], and HR = 0.47 [95% CI 0.26-0.86] in CS-1, CS-2, and CS-3, respectively). By hypothesizing an extension of coronary reperfusion therapy utilization rate in CS-2 and CS-3 to that in CS-1, from 21 (crude analysis) to 20 (adjusted analysis) deaths were classified as potentially avoidable.

CONCLUSION

Increased mortality in patients with chronic comorbidity and STEMI derives, at least in part, from underutilization of coronary reperfusion therapy, and might be reduced with a more aggressive therapeutic approach.

Effect of Emergency Percutaneous Coronary Intervention on In-Hospital Mortality of Very Elderly (80+ Years of Age) Patients With Acute Myocardial Infarction

It is still controversial whether percutaneous coronary intervention (PCI) is effective in improving in-hospital survival in very elderly patients. Therefore, using data from the Tokai Acute Myocardial Infarction Study II, we studied the effect of emergency PCI on the in-hospital mortality of very elderly (80+ years of age) patients with acute myocardial infarction (AMI). The study was a prospective study of all consecutive patients admitted to the 15 acute care hospitals in the Tokai region with the diagnosis of AMI from 2001 to 2003. A total of 211 patients undergoing emergency PCI and 176 patients not undergoing PCI were included in the present analysis. We compared the baseline and procedural characteristics and the clinical outcomes between the 2 groups. Patients without emergency PCI were older and had an increased prevalence of female gender, ADL impairment, and dementia in comparison with those with PCI. They also showed poorer clinical conditions. They were less likely to be transferred to intensive care or coronary care units and to be given intra-aortic balloon pumps. The patients with emergency PCI had nearly one-third the in-hospital mortality rate of the patients without emergency PCI. According to multivariate analysis, emergency PCI was still identified as an independent predictor of in-hospital death, with an adjusted odds ratio of 0.26 (95% CI, 0.07-0.97). The results indicated that emergency PCI has a preventative effect on in-hospital mortality in Japanese AMI patients 80 years of age and older.