AT ACC 17
WASHINGTON (FRONTLINE MEDICAL NEWS) – Patients who experience an acute MI at age 65 or older have unsettlingly high 5- and 10-year mortality in community practice settings despite excellent rates of evidence-based medications being prescribed at discharge, Ajar Kochar, MD, reported at the annual meeting of the American College of Cardiology.
This observation is based upon more than 22,000 patients aged 65 years or older treated for an acute MI during 2004-2006 at 344 U.S. hospitals participating in the CRUSADE registry. Their median age at the time of MI was 77 years. But 10-year all-cause mortality remained high even among relatively younger patients aged 65-74 whom one would expect to have a favorable long-term prognosis because they had additional survival-enhancing factors working in their favor, including having undergone coronary revascularization during their index hospitalization and surviving their first year post-MI, observed Dr. Kochar of the Duke Clinical Research Institute in Durham, N.C.
“Our sobering long-term mortality results demonstrate an unmet need in addressing the long-term outcomes in older MI patients,” according to Dr. Kochar.
This unmet need will increasingly clamor for attention as the aging of the American population accelerates like a runaway freight train. By 2030, an estimated 20% of Americans will be aged 65 or older. That’s more than 71 million people. And more than half of all MIs occur in individuals above age 65, he noted.
Dr. Kochar presented a CRUSADE analysis which included 19,755 older Americans with a non–ST elevation MI (NSTEMI) and 2,540 with a STEMI. The overall group’s 1-year mortality was 24%, with a 5-year cumulative mortality of 51% and a whopping 10-year mortality of 72%.
According to the Centers for Disease Control and Prevention, the expected additional lifespan of someone who was 65 years old in 2015 is 19 years. In contrast, the median survival of patients in the CRUSADE registry who were 65-69 at the time of their MI was less than half of that, at 8.3 years.
Among the key findings from the CRUSADE analysis:
• Unadjusted 10-year all-cause mortality was significantly greater in patients with NSTEMI than STEMI, by a margin of 73% versus 60%. Notably, however, NSTEMI patients were far less likely to undergo coronary revascularization: 32% of them had percutaneous coronary intervention during their index hospitalization, and 8.7% underwent coronary artery bypass grafting, in contrast to rates of 65.5% for PCI and 8.0% for CABG in the STEMI patients. After adjustment for these and other differences in care, NSTEMI patients actually had a 7% lower risk of long-term mortality than the STEMI group.
• Even after limiting the analysis to the youngest elderly – patients aged 65-74 when their MI occurred – 10-year mortality remained high, at 53%.
• After excluding the 24% of patients who died within 1 year after MI, 10-year mortality was still quite high, at 63%. Dr. Kochar and his coinvestigators chose to reanalyze the data in this way because the 1-year mark is an important time point clinically, since it’s when decisions regarding extended dual-antiplatelet therapy are made.
Patients who underwent coronary revascularization during their index hospitalization had a much-improved long-term prognosis, compared with those with medical management only. The 10-year cumulative mortality rate was 57% in patients who had PCI, identical at 57% in those who received CABG, and 84% in medically managed patients.
Ninety-five percent of patients were discharged on aspirin, 94% on a beta blocker, 81% on a statin, and 73% on clopidogrel. Discharge prescriptions for statins and clopidogrel were more common for the STEMI group. Unfortunately, the CRUSADE registry doesn’t include data on long-term medication adherence or prescription refill rates.
Dr. Kochar named several potential strategies aimed at reducing the high long-term mortality rates in older patients with MI as documented in this study. These include structured efforts to improve adherence to evidence-based medications for secondary prevention, as well as making percutaneous revascularization more widely available for older patients with NSTEMI. He noted that while in 2004-2006, 32% of CRUSADE participants with NSTEMI underwent PCI during their index hospitalization, by 2011-2012 that rate had inched upward only to 36%.
Several physicians commented that the high long-term all-cause mortality rates in older CRUSADE participants may paint a grim picture, in part because the aged face growing risks of cancer and other noncardiovascular competing causes of death. But Dr. Kochar replied that while the lack of information on specific causes of death is a study limitation, he and his coinvestigators are convinced based upon data from other studies that most of the deaths in CRUSADE were cardiovascular in nature.
He reported having no financial conflicts regarding his study.