Clinical research study
Changes in One-Year Mortality in Elderly Patients Admitted with Acute Myocardial Infarction in Relation with Early Management

https://doi.org/10.1016/j.amjmed.2016.12.005Get rights and content

Abstract

Background

Elderly patients are underrepresented in acute myocardial infarction trials. Our aim was to determine whether, in elderly patients, changes in management in the past 15 years are associated with improved 1-year mortality after hospital admission for myocardial infarction.

Methods

We used data from 4 1-month French registries, conducted 5 years apart from 1995 to 2010, including 3389 elderly patients (≥75 years of age).

Results

From 1995 to 2010, mean age remained stable (82.1 years), similar in ST- and non-ST-elevation myocardial infarction patients. Obesity, diabetes, hypertension, and hypercholesterolemia increased. History of prior myocardial infarction, stroke, and peripheral artery disease remained stable, while history of heart failure decreased. Major changes in management were noted: early percutaneous coronary intervention, early treatment with antiplatelet agents, low-molecular-weight heparin, beta-blockers, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and statins all increased. Early mortality after hospital admission decreased from 25.0% to 8.4%. One-year mortality decreased from 36.2% to 20.0% (adjusted hazard ratio 2010 vs 1995: 0.47, 0.39-0.57), both for ST-elevation myocardial infarction (36.8% to 21.1%) and non-ST-elevation myocardial infarction (34.8% to 19.1%). Mortality reduction was observed in all age groups, including those ≥85 years of age (from 46.2% to 31.4%). The study period, however, was no longer associated with decreased mortality when variables reflecting management changes were taken into account.

Conclusions

Early and 1-year mortality after hospital admission of elderly patients with acute myocardial infarction has substantially decreased over the past 15 years. This improvement is likely mediated by increasing use of recommended management strategies. These data support the application of guidelines derived from trials mostly including younger patients to elderly populations as well.

Section snippets

Study

Four nationwide French registries were conducted 5 years apart from 1995 to 2010: USIK 1995,17 USIC 2000,18 French Registry of Acute ST-Elevation or non-ST-elevation Myocardial Infarction (FAST-MI) 2005 (NCT00673036),19 and FAST-MI 2010 (NCT01237418).20 The methods used have been described previously.17, 18, 19, 20 Briefly, their primary objectives were to evaluate the characteristics, management, and outcomes of acute myocardial infarction patients, as seen in routine clinical practice, on a

Study Population

There were 3389 elderly patients enrolled in the 4 surveys (Table 1). The proportion of elderly patients remained stable over time in non-ST-elevation myocardial infarction patients (1995: 36.4%, 2010: 38.4%), but decreased in ST-elevation myocardial infarction patients (1995: 29.9%, 2010: 25.5%). Mean age remained stable; among risk factors, hypertension, diabetes, obesity, and hypercholesterolemia increased. Previous myocardial infarction remained stable while history of myocardial

Discussion

In this study, early and 1-year mortality in elderly patients admitted for acute myocardial infarction decreased by 50% in the past 15 years. Mortality decrease was observed in all age classes, including the very elderly, and was related to both improved 30-day survival and, to a lesser extent, improved survival beyond 30 days. Both increased use of early percutaneous coronary intervention, use of alternative anticoagulants instead of unfractionated heparin and early use of recommended

Conclusions

One-year mortality of elderly patients with acute myocardial infarction has decreased by 50% in the past 15 years in France, mainly driven by a strong reduction in early mortality. Changes in early management seem more determinant than changes in population characteristics to explain this reduction. These data, also observed in the population of very elderly individuals, therefore strongly suggest that it is reasonable to apply the recommendations drawn from randomized trials performed in

Acknowledgment

The authors are deeply indebted to all patients and physicians participating in the surveys.

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    Funding: USIK 1995 was funded by Laboratoire Roussel, which was involved in the design and conduct of the study, as well as data collection and management. USIC 2000 was funded by Aventis-France, which was involved in the design and conduct of the study, as well as data collection and management. FAST-MI 2005 and FAST-MI 2010 are registries of the French Society of Cardiology. FAST-MI 2005 was supported by unrestricted grants from Pfizer and Servier, and an additional grant from the Caisse Nationale d'Assurance Maladie-Travailleurs Salariés. FAST-MI 2010 was supported by unrestricted grants from AstraZeneca, the Daiichi-Sankyo-Eli-Lilly alliance, GlaxoSmithKline, Merck, Novartis, and Sanofi-Aventis. None of the companies had a role in the design and conduct of the study, data collection, or management. They were not involved in the analysis and interpretation of the data, nor in the preparation, review, or approval of the manuscript.

    Conflict of Interest: EP reported speaker, board membership, and consulting fees: Amgen, AstraZeneca, Bayer, Daiichi Sankyo, Lilly, MSD, Sanofi-Aventis. NA reported speaker fees: Astra Zeneca. GC reported grants to the Institution or Consulting/lecture fees from: Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Boston, Biotronik, BMS, Daiichi Sankyo, Eli-Lilly, Europe, Fédération Française de Cardiologie, Fondation Coeur et recherche, Medtronick, MSD, Pfizer, Sanofi-Aventis, The Medicines Company. DB reported lectures and consulting fees for Edwards LifeSciences. ME reported research grants to the Institution from Boston Inc or Symposia and consulting fees from Bayer, Jansen Cilag, Bristol-Myers-Squibb, Pfizer, AstraZeneca, Daiichi-Sankyo. PH reported disclosures from Astra-Zeneca and Bayer. FS reported receiving grant support to his institution and travel support for scientific meetings: Amgen, AstraZeneca, Boehringer-Ingelheim, BMS Daiichi–Sankyo, Lilly, Medtronic, Merck, Pfizer, Sanofi Aventis, and Servier. JF reported receiving grants and speaker fees: Amgen, MSD and Sanofi. TS reported institutional grants from AstraZeneca, Daiichi-Sankyo, Eli-Lilly, GSK, MSD, Novartis, and Pfizer; personal fees from board membership, consultancy, or lecture from AstraZeneca, Astellas, Bayer, BMS, Lilly, MSD, and Sanofi. ND reported receiving research grants: AstraZeneca, Daiichi-Sankyo, Eli-Lilly, Glaxo-Smith-Kline, MSD, Novartis, Pfizer, Sanofi Aventis, Servier, and The Medicines Company; and advisory panels or lecture fees: AstraZeneca, Boehringer-Ingelheim, Bristol-Myers Squibb, Eli-Lilly, Menarini, Merck-Serono, Novo-Nordisk, Servier, and Sanofi Aventis. ER, AL, MM, OS-J, PJ, VB, ED, and GM reported no conflicts of interest for the present study.

    Authorship: All authors had access to the data and played a role in writing this manuscript.

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