Elsevier

American Heart Journal

Volume 162, Issue 2, August 2011, Pages 283-290.e2
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
Quality of acute myocardial infarction care and outcomes in 33,997 patients aged 80 years or older: Findings from Get With The Guidelines-Coronary Artery Disease (GWTG-CAD)

https://doi.org/10.1016/j.ahj.2011.04.017Get rights and content

Objectives

To determine the adherence to national guidelines and in-hospital mortality of older patients with acute myocardial infarction (AMI) using a national database.

Background

Prior studies have demonstrated that older patients are less likely to receive evidence-based therapies.

Methods

Using data from the GWTG-CAD, we examined care and in-hospital outcomes among AMI patients treated at 416 US centers from 2000 to 2009. Evidence-based medical therapy, other quality measures, and in-hospital post-AMI mortality were analyzed.

Results

A total of 156,677 patients were included in the study; 21.7% (n = 33,997) were aged ≥80 years, 33.0% (n = 51,773) 65 to 79 years, and 45.3% (n = 70,907) 18 to 64 years. Older patients had higher prevalence of comorbidities compared to younger patients. Overall, compliance with evidence-based medical treatment upon admission and discharge was high, but age-related differences in care were seen for most measures. After multivariate adjustment, the mortality of the patients aged ≥80 years was substantially higher compared to the youngest cohort (adjusted OR 3.4, 95% CI 3.2-3.8, P < .0001). There were substantial improvements in AMI quality measures over time in each age group.

Conclusions

Among AMI patients aged ≥80 years, the use of evidence-based therapies was high and significant improvements over time have been observed in a national quality improvement program. Nevertheless, there remain important age-related gaps in care and outcomes, suggesting opportunities exist to improve prognosis in this high-risk population.

Section snippets

Methods

The primary data were derived from the American Heart Association's GWTG-CAD registry. This initiative, promoting performance improvement strategies and higher adherence to national guidelines,11, 12, 13 was performed in different types of medical centers across the United States. Hospitals submitted patients' data without financial compensation, and data were entered by highly trained hospital staff. Cases were based on identification of patients with the diagnosis of AMI and stratified into

Patient characteristics

The study population included 156,677 patients admitted with AMI. From these, 45.3% (n = 70,907) were aged 18 to 64, 33.0% (n = 51,773) 65 to 79, and 21.7% were ≥80 years (n = 33,997). Older patients (≥80 years) were more likely to be women, white, and had lower body mass indices as shown in Table I, and tended to have higher prevalence of most comorbidities except for COPD, DM, high lipids, peripheral vascular disease, and smoking.

Clinical performance measures

ASA and BB utilization in the first 24 hours was high in the

Discussion

This study, based on one of the largest contemporary cohorts in the United States with a substantial proportion of older adults, demonstrates that patients ≥80 years presenting with AMI have higher comorbidites, longer reperfusion times, and lower revascularization procedures rates compared to younger patients. These differences persist after adjustment for baseline characteristics. In addition, after AMI, older adults are less likely to be discharged on medications, which have demonstrated to

Conclusions

Among hospitals participating in GWTG-CAD, there was high adherence with guideline-recommended therapies and significant improvements over time for patients ≥80 years old hospitalized with AMI. Nevertheless, there remain important gaps in care and outcomes for patients ≥80 years old after AMI. Older age group patients were less likely to receive mechanical reperfusion within 90 minutes and less likely to be discharged with ASA, BB, statins, and ACEi/ARB, even after controlling for other

Disclosures

Sources of Funding: GWTG-CAD is a program of the American Heart Association and is supported in part by an unrestricted educational grant from Merck/Schering-Plough Pharmaceutical and Pfizer. The analysis of registry data was performed at Duke Clinical Research Institute (Durham, NC), which receives funding from the American Heart Association. The sponsors were not involved in the design, analysis, preparation, review, or approval of this manuscript.

Hector M. Medina, MD: National Institutes of

References (34)

  • R.J. Goldberg et al.

    Thirty-year trends (1975 to 2005) in the magnitude of, management of, and hospital death rates associated with cardiogenic shock in patients with acute myocardial infarction: a population-based perspective

    Circulation

    (2009)
  • N.I. Parikh et al.

    Long-term trends in myocardial infarction incidence and case fatality in the National Heart, Lung, and Blood Institute's Framingham Heart study

    Circulation

    (2009)
  • M. Myerson et al.

    Declining severity of myocardial infarction from 1987 to 2002: the Atherosclerosis Risk in Communities (ARIC) Study

    Circulation

    (2009)
  • Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group

    Lancet

    (1994)
  • P.Y. Lee et al.

    Representation of elderly persons and women in published randomized trials of acute coronary syndromes

    Jama

    (2001)
  • W. Rosamond et al.

    Heart disease and stroke statistics—2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

    Circulation

    (2008)
  • The State of Aging and Health in America Report 2007

  • Cited by (19)

    • Sex and Gender Disparities in the Management and Outcomes of Acute Myocardial Infarction–Cardiogenic Shock in Older Adults

      2020, Mayo Clinic Proceedings
      Citation Excerpt :

      Though not the focus in this study, our study is consistent with improved survival associated with PCI in this population of older AMI-CS admissions (adjusted OR, 0.65; 95% CI, 0.62-0.67; P<.001). In addition to PCI, older patients frequently receive delayed revascularization and lower rates of guideline-directed medical therapy during and after the acute care hospitalization.41 However, because this study was focused on older patients, we did not compare this cohort with the population younger than 75 years.

    • Validity of in-hospital mortality data among patients with acute myocardial infarction or stroke in National Health Insurance Research Database in Taiwan

      2015, International Journal of Cardiology
      Citation Excerpt :

      The reduction of the in-hospital mortality rate of acute myocardial infarction (AMI) or stroke is an important quality indicator for hospital performance or procedures, such as percutaneous coronary intervention or thrombolytic therapy, among these patients [1–4]. Population-based administration or claims database are two valuable resources to perform epidemiological studies and healthcare quality evaluation [5,6]. Understanding the underlying diseases (e.g. AMI or stroke) of mortality events has significant clinical, economic, and quality-of-life implications.

    • Correlation between comprehensive evaluation of coronary artery lesion severity and long-term clinical outcomes in chinese octogenarians with acute coronary syndrome

      2014, Heart Lung and Circulation
      Citation Excerpt :

      About 21.7% of AMI patients (n = 156,677) were ≥80 years old. Older patients had a higher prevalence of comorbidities compared with younger patients, and the mortality of the patients ≥80 years old was substantially higher compared with the youngest cohort [18,19]. Accordingly, it is very important to accurately evaluate the risk factors for coronary artery lesion severity in ACS patients > 80 years old, and to perform effective therapeutic interventions.

    • Encouraging trends in acute myocardial infarction survival in the oldest old

      2013, American Journal of Medicine
      Citation Excerpt :

      In the present study, we did not observe such a large increase in coronary reperfusion therapy use, suggesting that our findings are predominantly related to increased use of guideline-based medications. Similar results were reported in a study from the Get With The Guidelines–Coronary Artery Disease project, which included more than 30,000 patients with an acute coronary syndrome (mean age, 85 years) hospitalized at more than 400 US medical centers between 2002 and 2009.21 In this population, the use of evidence-based cardiac therapies during hospitalization increased significantly during the study period, whereas the in-hospital death rate declined.

    View all citing articles on Scopus

    Sorin J. Brener, MD, served as guest editor for this article.

    f

    On behalf of the GWTG Steering Committee and Investigators.

    View full text