Trends in outcomes among older patients with non-ST-segment elevation myocardial infarction

Prognosis Between ST-Elevation and Non-ST-elevation Myocardial Infarction in Older Adult Patients

Background: Whether there is a difference in prognosis between elderly patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) remains mysterious.

Methods: We conducted a retrospective cohort study by analyzing the data in the Longitudinal Health Insurance Database (LHID) in Taiwan to explore differences between STEMI and NSTEMI with respect to in-hospital and long-term (3-year) outcomes among older adult patients (aged ≥65 years). Patients were further stratified based on whether they received coronary revascularization.

Results: In total, 5,902 patients aged ≥65 years with acute myocardial infarction (AMI) who underwent revascularization (2,254) or medical therapy alone (3,648) were included. In the revascularized group, no difference was observed in cardiovascular (CV) and all-cause mortality during hospitalization or at 3-year follow-up between the two AMIs. Conversely, in the non-revascularized group, patients with NSTEMI had higher crude odds ratio (cOR) for all-cause death during hospitalization [cOR: 1.33, 95% confidence interval (CI) = 1.07–1.65] and at 3-year follow-up (cOR: 1.47, 95% CI = 1.21–1.91) relative to patients with STEMI. However, after multivariable adjustments, only NSTEMI indicated fewer in-hospital CV death [adjusted odds ratio (aOR): 0.75, 95% CI = 0.58–0.98] than STEMI in non-revascularized group. Moreover, major bleeding was not different between patients with STEMI or NSTEMI aged ≥65 years old.

Conclusion: Classification of AMI is not associated with the difference of in-hospital or 3-year CV and all-cause death in older adult patients received revascularization. In a 3-year follow-up period, STEMI was an independent predictor of a higher incidence of revascularization after the index event. Non-ST-elevation myocardial infarction had more incidence of MACE than patients with STEMI did in both treatment groups.

Temporal Pattern of CABG and PCI after Non-ST Elevation Myocardial Infarction Among Elderly Patients from NHDS

Background

Management of elderly patients with Non-ST Elevation Myocardial Infarction (NSTEMI) continues to be a source of controversy due to underrepresentation in large-scale clinical trials and the increased risk of adverse outcomes after both invasive (Percutaneous coronary intervention and Coronary artery bypass grafting) and non-invasive therapies. Recent randomized clinical trials have shown improved short term and intermediate term outcomes among high risk NSTEMI patients receiving early invasive management versus conservative medical management. However, how this is reflected in U.S. clinical practice for elderly patients has not been reported.

Objective

To identify the trend of invasive management in patients with NSTEMI, particularly among elderly population.

Methods

We used data from National Hospital Discharge Survey to identify all adult patients with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for NSTEMI from the years 2005 to 2009. The goal was to investigate the trends in time of invasive therapy for patients diagnosed with NSTEMI. We then stratified the patients according to age >65 and ≤65, and compared the temporal trends between two age groups.

Results

Among 21,306 patients diagnosed with NSTEMI between 2005 and 2009, the median age was 73 years (IQR: 61-82 years), 54% were males and 57% were White. The proportions of patients age>65 years receiving invasive management (21%, N=13978) was significantly lower than those age≤65 (41%, N=7328) (p<0.001). Moreover, in both age groups, the proportion of patients receiving early invasive management decreased substantially over time (p<0.001).

Conclusion

Despite numerous studies promoting the use of early invasive management for NSTEMI patients, the proportion of patients receiving invasive intervention gradually decreased from 2005-2009, more so in elderly population. The decrease seen in overall proportion of patients receiving invasive therapy could be associated with older median age of NSTEMI patients; 73 years (IQR: 61-82). Our future analyses will investigate if this trend maintains after adjusting for other factors (sex, co-morbid conditions, insurance status, year of procedure, hospital region, and hospital bed-size) thought to be associated with the management of NSTEMI in elderly patients.

Age, knowledge, preferences, and risk tolerance for invasive cardiac care

BACKGROUND/OBJECTIVES

The extent to which individual knowledge, preferences, and priorities explain lower use of invasive cardiac care among older vs. younger adults presenting with acute coronary syndrome (ACS) is unknown. We directly surveyed a group of patients to ascertain their preferences and priorities for invasive cardiovascular care.

DESIGN

We performed a prospective cohort study of adults hospitalized with ACS. We surveyed participants regarding their knowledge, preferences, goals, and concerns for cardiac care, as well as their risk tolerance for coronary artery bypass grafting (CABG).

SETTING

Single academic medical center.

PARTICIPANTS

Six hundred twenty-eight participants (373 <75 years old; 255 ≥75 years old).

MEASUREMENTS

We compared baseline characteristics, knowledge, priorities, and risk tolerance for care across age strata. We also assessed pairwise differences with 95% confidence intervals (CI) between age groups for key variables of interest.

RESULTS

Compared with younger patients, older participants had less knowledge of invasive care; were less willing to consider cardiac catheterization (difference between 75-84 and< 65 years old: -7.8%, 95% CI: -14.4%,-1.3%; for ≥85 vs. <65: -15.7%, 95% CI: -29.8%,-1.6%), percutaneous coronary intervention (difference between 75-84 and< 65 years old: -12.8%, 95% CI: -20.8%,-4.8%; for ≥85 vs. <65: -24.8%, 95% CI: -41.2%,-8.5%), and CABG (difference between 75-84 and< 65 years old: -19.0%, 95% CI: -28.2%,-9.9%; for ≥85 vs. <65: -39.1%, 95% CI: -56.0%,-22.2%); and were more risk averse for CABG surgery (p < .001), albeit with substantial inter-individual variability and individual outliers. Many patients who stated they were not initially willing to undergo an invasive cardiovascular procedure actually ended up undergoing the procedure (49% for cardiac catheterization and 22% for PCI or CABG).

CONCLUSION

Age influences treatment goals and willingness to consider invasive cardiac care, as well as risk tolerance for CABG. Individuals' willingness to undergo invasive cardiovascular procedures loosely corresponds with whether that procedure is performed after discussion with the care team.

Comparison of Outcomes of Acute Coronary Syndrome in Patients ≥80 Years Versus Those <80 Years in Israel from 2000 to 2013

Although patients ≥80 years old constitute the fastest-growing segment of the population and have a high prevalence of coronary artery disease, few data exist regarding the outcome of octogenarians with acute coronary syndrome (ACS). In a retrospective study based on data of 13,432 ACS patients who were enrolled in the ACS Israel Survey, we first evaluated the clinical outcome of 1,731 ACS patients ≥80 years (13%) compared with 11,701 ACS patients <80 years (87%) hospitalized during 2000 to 2013. Second, we evaluated the clinical outcome of patients ≥80 years hospitalized during the 2000 to 2006 ("early") period (n = 1,037) compared with those of the same age group of patients hospitalized during the 2008 to 2013 ("late") period (n = 694). Implementation of the ACS AHA/ACC/ESC therapeutic guidelines was lower in ACS patients ≥80 years compared with patients <80 years. Multivariate Cox regression analysis demonstrated a worse 1-year survival rate in the ACS patients ≥80 years compared with those <80 years. During the late period, patients ≥80 years were more frequently treated with guideline-recommended therapies compared with patients from the same age group who were hospitalized in the early period. Multivariate Cox regression analysis demonstrated a better 1-year survival rate of patients ≥80 years during the late period compared with the early period (hazard ratio 1.17, 95% confidence interval 1.15 to 1.61; p = 0.01). In addition, adverse outcome rates of ACS patients ≥80 years were significantly higher compared with those of patients <80 years. However, survival rates of ACS patients ≥80 years were improved over the 200 to 2013 period.

Monocyte/lymphocyte ratio predicts the severity of coronary artery disease: a syntax score assessment

Background

We aimed to explore whether monocyte to lymphocyte ratio (MLR) provides predictive value of the lesion severity in patients with coronary artery disease (CAD).

Methods

Five hundred forty-three patients undergoing coronary angiography were analyzed in this retrospective study. Patients with coronary stenosis were divided into three groups on the basis of Syntax score. The control group consisted of patients with normal coronary arteries. MLR was calculated by dividing monocytes count by lymphocytes count obtained from routine blood examination. Multivariate logistic analysis was used to assess risk factors of CAD. Ordinal logistic regression analysis was used to assess the relationship between MLR and the lesion severity of coronary arteries.

Results

MLR was found to be an independent risk factor of the presence of CAD (OR: 3.94, 95% CI: 1.20–12.95) and a predictor of the lesion severity (OR: 2.05, 95% CI: 1.15–3.66). Besides, MLR was positively correlated with Syntax score(r = 0.437, p < 0.001). In the receiver-operating characteristic (ROC) curve analysis, MLR, with an optimal cut-off value of 0.25, predicted the severe coronary lesion with a sensitivity of 60.26% and specificity of 78.49%.

Conclusions

MLR was an independent risk factor of the presence of CAD, and a predictor of the lesion severity. Compared to neutrophil to lymphocyte ratio (NLR), MLR has better performance to reflect the severity of coronary lesion.

Differences in Short- and Long-Term Outcomes Among Older Patients With ST-Elevation Versus Non–ST-Elevation Myocardial Infarction With Angiographically Proven Coronary Artery Disease

Background—

Among older patients with acute myocardial infarction (MI), it remains uncertain whether there is a time-dependent difference in the risk of recurrent mortality and nonfatal cardiovascular and cerebrovascular events for those with ST-segment–elevation MI (STEMI) compared with those with non–ST-segment–elevation MI.

Methods and Results—

Older patients ≥65 years with acute MI and significant coronary artery disease identified with coronary angiography from the ACTION Registry-GWTG (Get With the Guidelines) were linked to Medicare claims data from 2007 to 2010. We examined the unadjusted cumulative incidence of each outcome studied from hospital discharge through 2 years with log-rank tests and then performed a piece-wise proportional hazards modeling with 2 time periods: discharge to 90 days and 90 days to 2 years. Among the 46 199 patients linked with Medicare data, 17 287 (37.4%) presented with STEMI. Through 2 years, the unadjusted cumulative incidence of all-cause mortality (16.0% versus 19.8%; P <0.001) and the composite outcome (21.9% versus 27.9%; P <0.001) was lower for STEMI patients. Within the first 90 days, unadjusted rates of mortality (5.5% versus 5.3%) and the composite outcome (7.9% versus 8.1%) were similar but diverged from 90 days to 2 years (mortality, 11.1% versus 15.4%; P <0.001; composite outcome, 15.2% versus 21.5%; P <0.001). After multivariable adjustment, the adjusted risks of mortality and the composite outcome through 90 days were higher for STEMI patients, whereas risks of mortality and the composite outcome were attenuated from 90 days through 2 years.

Conclusions—

Among older acute MI patients with angiographically confirmed coronary artery disease discharged alive, STEMI patients (compared with non–ST-segment–elevation MI patients) were found to have a lower frequency of unadjusted postdischarge mortality and composite cardiovascular and cerebrovascular outcomes through 2 years after hospital discharge. This analysis provides unique insight into differential short- and long-term risks of ischemic cardiovascular and cerebrovascular outcomes by MI classification among older MI patients with confirmed coronary artery disease surviving to hospital discharge.

Outcomes of non-STEMI patients transported by emergency medical services vs private vehicle

BACKGROUND

Non-ST-segment elevation myocardial infarctions (NSTEMIs) are more common but less studied than ST-segment elevation myocardial infarctions (STEMIs) treated by emergency medical services (EMS).

OBJECTIVE

The purpose of this study was to evaluate the differences in baseline characteristics and outcomes of NSTEMI patients when arriving by EMS vs self-transport.

METHODS

We performed a retrospective medical record review of 96 EMS patients and 96 self-transport patients with the diagnosis of NSTEMI based on billing code.

RESULTS

The mean age of patients arriving by EMS was 75 vs 65 years for self-transport patients (P≤ .000). Patients arriving by self-transport received cardiac catheterization more often than patients arriving by EMS (84% vs 49%, P≤ .001). Emergency medical services patients had significantly longer average hospital length of stay and intensive care unit length of stay than did patients arriving by self-transport (6.5 vs 4 days [P≤ .001] and 4.1 vs 2.7 days [P= .019]). Significantly more EMS patients were discharged to a new extended care facility (25% vs 3.1%, P≤ .001). Finally, more EMS patients died in the hospital (18.8 vs 4.2%, P= .002).

CONCLUSIONS

Patients with NSTEMI who arrived by EMS are older, are more ill, and have worse outcomes compared with patients who arrived by self-transport. Further research into patient reasoning for mode of transportation to the ED may influence public health interventions, public policy development, and EMS and hospital protocols for management of NSTEMIs. The high mortality in prehospital cohort should prompt further investigation to develop evidence-based protocols.

Non-ST-elevation myocardial infarction in the United States: contemporary trends in incidence, utilization of the early invasive strategy, and in-hospital outcomes

Background

There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non‐ST‐elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in‐hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in‐hospital outcomes of NSTEMI in the United States.

Methods and Results

We analyzed the 2002–2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age‐, sex‐, and race/ethnicity‐stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age‐, sex‐, and race/ethnicity‐stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (P_trend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (P_trend<0.001). Risk‐adjusted in‐hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978).

Conclusions

There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in‐hospital mortality and length of stay.