Changes in management of elderly patients with myocardial infarction

• Published in: European heart journal 2009-04, Vol.30 (8), p.987-994
• Main Authors: Schiele, François, Meneveau, Nicolas, Seronde, Marie France, Descotes-Genon, Vincent, Oettinger, Joanna, Ecarnot, Fiona, Bassand, Jean-Pierre
• Format: Article
• Language: English
• Subjects: Acute myocardial infarction; Aged, 80 and over; Biological and medical sciences; Cardiology. Vascular system; Cardiotonic Agents - therapeutic use; Coronary heart disease; Elderly; Epidemiologic Methods; Female; France - epidemiology; Guidelines; Health Services for the Aged - trends; Heart; Humans; Male; Medical sciences; Myocardial Infarction - drug therapy; Myocardial Infarction - mortality; Myocardial Reperfusion - mortality; Myocarditis. Cardiomyopathies; Practice Guidelines as Topic; Quality of care
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/eurheartj/ehn601

Aims Despite being at higher risk for mortality, elderly patients (≥75 years) admitted for acute myocardial infarction (MI) often receive fewer effective therapies, because of contraindications or higher risk of drug-induced adverse events. The aim of this study was to assess the changes in the use of effective treatments between 2001 and 2006 in elderly patients, and the relation with 1-month mortality. Methods and results Prospective, multicentre registry, considering two periods: 6 months between October 2000 and March 2001 (cohort 1) and 12 months between October 2005 and October 2006 (cohort 2). Demographic and clinical characteristics at admission, in-hospital treatment (reperfusion or early invasive therapy, oral antiplatelets, anticoagulants, angiotensin-converting enzyme (ACE)-inhibitors, beta-blockers, and statins), and 1-month survival were compared between the two cohorts, after adjustment on a propensity score (for being admitted in 2001). Eight hundred and sixty-eight elderly patients were included, 280 in cohort 1 and 588 in cohort 2. When compared with cohort 1, patients from cohort 2 presented with comparable characteristics, except for the Global Registry of Acute Coronary Events risk score and we observed a significant increase in the use of aspirin, clopidogrel, reperfusion therapy, ACE-inhibitors, and statins in cohort 2. One-month mortality was significantly lower in cohort 2 (13.6% in cohort 1 vs. 7.1% in cohort 2, P = 0.001), mainly driven by a decrease in the mortality among patients with ST-segment elevation MI (23.3% in cohort 1 vs. 9.2% in cohort 2, P < 0.001). Adjustment on the propensity score did not alter these results. By multivariable analysis, the three-fold higher mortality in patients from cohort 1 was offset when the rate of use of treatments was considered in the model, suggesting that the treatment intensity was related to lower mortality. Conclusion Between 2001 and 2006, a significant increase in the use of guidelines-recommended treatments (GRTs) was observed, associated with lower 30-day mortality, in elderly patients. These data confirm that high-risk patients, such as the elderly, benefit from an increase in the use of GRTs.