Monday, November 7, 2005

Elderly Patients with Acute Coronary Syndrome Less Likely to Get Recommended Care
By Julie McKeel

Elderly patients with acute coronary syndrome (ACS) are not receiving the same standard of care as younger patients, despite the fact that they would gain as much benefit, if not more, from some of the treatments, a new observational multicenter study finds.

Karen Alexander, MD

However, the investigators noted that patients over 75 who did receive treatment that followed American College of Cardiology/American Heart Association (ACC/AHA) guidelines had the same reduced risk of death as their younger counterparts.

Alexander's team collected information on 56,963 patients treated at 443 hospitals across the U.S. for the CRUSADE* National Quality Improvement Initiative.

[CRUSADE = Can Rapid risk stratification of Unstable angina patients Suppress ADverse Event outcomes with early implementation of the ACC/AHA guidelines? was designed to increase the practice of evidence-based medicine for patients diagnosed with non-ST-segment-elevation ACS based on ACC/AHA guidelines.]

Patients were split into four age groups (younger than 65, 65-74, 75-84, and 85 or older). A multi-variable model tested for age-related differences in treatments and outcomes after adjusting for patient, physician, and hospital factors. Thirty-five percent of the patients were 75 or older, while 11% were 85 or older.

The new guidelines, the researchers note, do not offer different recommendations based on age, other than encouraging attention to preexisting conditions and appropriate drug dosing in elderly patients.

While most other studies in this field have looked at discharge medications and procedures—which Alexander's team also examined—the team also reviewed treatments provided within 24 hours of admission. They found that early use of heparin, GP IIb/IIIa inhibitors, and clopidogrel decreased significantly in those patients aged 75 or over. This is despite the fact that randomized clinical trials have shown the benefit of these drug treatments regardless of age, the investigators write.

According to the study results, elderly patients were less likely to receive antiplatelet and antithrombin therapy in the first 24 hours of care, less likely to receive recommended procedures, and less likely to be discharged on lipid-lowering agents and clopidogrel.

Specifically, of 92% of the ACS patients older than 85, only 29.9% were given clopidogrel and 12.8% received platelet glycoprotein IIb/IIIa inhibitors. After age 65, less than 50% received early invasive care, and that number fell to 11.2% after age 85.

This decrease in treatment received could be the result of several factors. First, older patients are less likely to arrive at the hospital complaining of chest pain, so their diagnosis is often delayed. The elderly are also more likely to have other conditions, such as heart failure or pneumonia, which may be the focus of the physician's initial care. Also, doctors may decide against certain treatment options in the elderly because of safety concerns, the researchers suggest.

But what of the potential harm caused by withholding effective treatments in high-risk elderly patients? The researchers suggest that physicians should also consider that repeated coronary events are most likely to occur early on in hospitalization, thus the lack of the use of early treatments contributes to adverse short-term outcomes.

One encouraging finding was that physicians were prescribing aspirin, beta blockers, and ACE inhibitors to their elderly patients on discharge in larger numbers, suggesting that providers are paying attention to the results of previous studies which showed that elderly patients were not receiving the appropriate medications at discharge.

In an editorial accompanying the study, Drs. H. Vernon Anderson of the University of Texas Health Science Center in Houston and Richard G. Bach of Washington University Medical Center in St. Louis note, "We need to invert the current equation so that instead of calculating a 'risk score' for ACS we should instead calculate an 'opportunity score.' Patients with higher baseline risks from the underlying disease—such as the elderly—would have higher opportunity scores for benefit, even allowing for some of the greater risks from treatment," they state in their editorial.

In fact, Alexander's team showed that this was the case. In-hospital death rates declined with the increase in the number of early recommended treatments received—those who received all five (cardiac catheterization, short-term aspirin, short-term beta blocker, short-term heparin, and short-term GP IIb/IIIa inhibitors) had a death rate of 5% or less. This improvement in the death rate was even greater for those patients aged 75 or over compared with those under 75.