Original title: Predictors of Treatment in Acute Coronary Syndromes in the Elderly: Impact on Decision Making and Clinical Outcome After Interventional Versus Conservative Treatment. Reference: Harald Rittger et al. Catheterization and Cardiovascular Interventions 80:735–743 (2012).
This study, recently published in Cath Cardiovasc Interven, was performed to determine the factors that helped physicians decide to be conservative or invasive. Were analyzed retrospectively 1,001 consecutive patients over 75 years who were admitted for acute coronary syndromes with or without ST segment elevation (NSTACS or STACS).
The decision to perform catheterization and eventually an angioplasty or coronary artery bypass graft surgery was at the discretion of the treating physicians. Out of the patients analyzed, 754 (76%) were admitted for SCANST and 776 (77.5%) received an invasive strategy. An analysis was performed by logistic regression for multiple baseline characteristics and in that way potential intricacies were identified.
Predictors for a conservative strategy were:
- Advanced age (the most powerful)
- Killip III functional class
- three-vessel injury
- Prior stroke
- Obesity
- Previous renal failure
- Type of acute coronary syndrome
- Previous infarction
- The presence of supraventricular arrhythmias.
Mortality from all causes in patients treated conservatively was 15.6% versus 3.5% of patients treated invasively, which is significantly in favor of an invasive strategy (p <0.001). The authors refer to an important limitation of the study: it is a retrospective analysis of a single center. However, the fact that patients are consecutive shows the reality of clinical practice beyond the trials and records for this age group.
Conclusion
In this analysis, older age was the strongest predictor for a conservative approach. Other features that are associated with increased clinical risk also tipped the balance towards conservative treatment.
Editorial comment
The management of elderly patients with acute coronary syndromes has not been standardized, given the lack of evidence coming from randomized and multicenter studies. The recommendations of the guidelines have been made mostly by transferring the results of studies in much younger patients, which often leaves older patients in the hands of its natural evolution, mainly from fear of medical complications.
These complications are, of course, more frequent in elderly patients but in no way counterbalance the potential benefit of an invasive strategy over total mortality rates. The proportion of elderly patients entering our hospitals is increasing, (and still growing), so this dilemma will become more common in all coronary care units.
Finally, we should bear in mind that we probably never have sufficient information from randomized and multicenter works designed specifically for elderly patients.
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