Abstract 13490: Patterns of In-Hospital Management and Disposition of Patients Over 90 Years of Age Admitted with an Acute Coronary Syndrome at a Tertiary Medical Center

Abstract

Introduction: It is estimated that by 2020 there will be 2.6 million nonagenarians and 135,000 centenarians in the United States. The in-hospital management and disposition of these patients remain poorly defined. Hypothesis: We describe in-hospital management and disposition of patients over the age of 90 years presenting with an acute coronary syndrome (ACS) at a tertiary medical center. Methods: All patients admitted between January 1, 2008 to December 31, 2012 with the diagnosis of an ACS and are over the age of 90 were included in this study. Demographic, clinical variables, in-hospital treatment, and post-hospital disposition were reviewed from medical records. The use of aspirin (ASA), beta-blockers, statins, ACEI/ARB, clopidogrel and aggressive versus conservative management were recorded. Results: 109 patients (13.9% males) were included. Demographics and clinical variables were as follows: Prior CAD 63.3%, prior MI 25.7%, renal insufficiency 33%, HT 80.7%, hyperlipidemia 45%, DM 23.9%, heart failure 30.3%, dementia 15.6%, smoking history 21.1%, and atrial fibrillation 22%. Patients were admitted from home 50.9%, nursing home/assisted living 35.2%, transfer from a local cath lab 12% and from primary care physician’s office 1.2%. ACS symptoms consisted of UA 23.9%, NSTEMI 65.4%, STEMI 11%. Coronary intervention was performed in 43.5%. Conservative management was driven by: dementia 4.6%, patient or family wishes 34.2%, physician 13%, non-treatable disease 4.6%. Pharmacologic management on discharge included ASA 82.1%, beta blockers 72%, statins 41.1%, ACEI 31.5%, ARB 8.3%, clopidogrel 52.4%. In-hospital mortality was 8.4% (cardiac related 7.5%) and length of hospital stay was 4.8 ± 4 days. Patients were discharged to home with visiting nurse (VN) support 30.1%, without VN 7.8%, to a family member’s home 4.9%, nursing home 29.1%, skilled nursing/rehabilitation 15.5%, and hospice 5.8%. Conclusions: In-hospital mortality rates of patients over the age of 90 is acceptable. Frequently these patients are treated with PCI. Conservative management is mostly guided by the patient and family wishes. Unfortunately, these patients remain markedly undertreated with standard post MI or UA drugs. Less than half of these patients returned home.