Long‐Term Mortality of Older Patients With Acute Myocardial Infarction Treated in US Clinical Practice

Abstract

BackgroundThere is limited information about the long‐term survival of older patients after myocardial infarction (MI).Methods and Results CRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines) was a registry of MI patients treated at 568 US hospitals from 2001 to 2006. We linked MI patients aged ≥65 years in CRUSADE to their Medicare data to ascertain long‐term mortality (defined as 8 years post index event). Long‐term unadjusted Kaplan–Meier mortality curves were examined among patients stratified by revascularization status. A landmark analysis conditioned on surviving the first year post‐MI was conducted. We used multivariable Cox regression to compare mortality risks between ST‐segment–elevation myocardial infarction and non–ST‐segment–elevation myocardial infarction patients. Among 22 295 MI patients ≥ age 65 years (median age 77 years), we observed high rates of evidence‐based medication use at discharge: aspirin 95%, β‐blockers 94%, and statins 81%. Despite this, mortality rates were high: 24% at 1 year, 51% at 5 years, and 65% at 8 years. Eight‐year mortality remained high among patients who underwent percutaneous coronary intervention (49%), coronary artery bypass graft (46%), and among patients who survived the first year post‐MI (59%). Median survival was 4.8 years (25th, 75th percentiles 1.1, 8.5); among patients aged 65–74 years it was 8.2 years (3.3, 8.9) while for patients aged ≥75 years it was 3.1 years (0.6, 7.6). Eight‐year mortality was lower among ST‐segment–elevation myocardial infarction than non–ST‐segment–elevation myocardial infarction patients (53% versus 67%); this difference was not significant after adjustment (hazard ratio 0.94, 95% confidence interval, 0.88–1.00).ConclusionsLong‐term mortality remains high among patients with MI in routine clinical practice, even among revascularized patients and those who survived the first year.

Incidence, outcomes, and predictors of in‐hospital acute coronary syndrome following endovascular transcatheter aortic valve replacement in the United States

“…We found that in‐hospital mortality and in‐hospital outcomes were worse in the TAVR with ACS cohort compared to TAVR patients without ACS. Previous studies have shown that in both STEMI and NSTE‐ACS, advanced age is independently associated with increased mortality 15,28 . Analysis of data from the CRUSADE registry of ACS patients (median age 77 years) revealed that the in‐hospital mortality was 7% 28 .…”

“…Previous studies have shown that in both STEMI and NSTE‐ACS, advanced age is independently associated with increased mortality 15,28 . Analysis of data from the CRUSADE registry of ACS patients (median age 77 years) revealed that the in‐hospital mortality was 7% 28 . In our ACS cohort, the in‐hospital mortality was slightly higher (9.6%) compared to these studies, possibly because of the fact that TAVR patients are frail at baseline, with higher Society of Thoracic Surgeons (STS) surgical risk score and in‐hospital mortality 16 .…”

The “Elderly” in Medicine: Ethical Issues Surrounding This Outdated and Discriminatory Term

“…Anti-elderly bias has also found its way into medicine: Reuben and coworkers 11 found in their five campus-wide study that medical students had “already formed some unfavorable attitudes about older persons.” In their words, students were “much less likely to admit an acutely ill 85-year-old woman to an intensive care unit, intubate her, and treat her aggressively than they were to treat an acutely ill 10-year-old girl with underlying chronic leukemia.” We feel comfortable, as we should be, to start treatments in younger patients with malignant diseases, despite median survivals of less than 1 or 2 years, yet it is surprising that we are hesitant to treat an older patient with benign diseases who might have a much longer life expectancy. Furthermore, without ill intentions, some investigators arbitrarily lump those over 65 years of age into one group, 12,13 as though treatment should be the same for everyone in that group, rather than for each patient as an individual.…”

Development and validation of nomogram to predict long-term prognosis of critically ill patients with acute myocardial infarction

“…The overall prevalence of AMI among adults over the age of 20 years old in the United States is 3.0% according to NHANES data from 2013 to 2016, and an American will suffer from AMI approximately every 40 seconds [2]. Moreover, the prognosis of AMI is poor, with a 5-year mortality rate as high as 51%, which heavily threatens human health and causes a great socioeconomic burden [3]. In view of this, the identification and development of risk factors or models for identifying high-risk patients is of great significance to improve the prognosis of patients, because advanced interventions can be timely taken.…”