The rate of coronary angiography refusal in older patients with non-ST elevation acute coronary syndrome and its impact on all-cause mortality

Objectives: Significant number older patients with acute coronary syndrome (ACS) cannot undergo coronary angiography (CAG) due to various comorbidities. Patient's refusal of invasive procedures is common among old patients and has not been thoroughly investigated in the context of ACS. We wanted to assess CAG refusal rate and its impact on all-cause mortality in older patients with non-ST elevation acute myocardial infarction. Methods: In this retrospective study, patients over 75 years of age admitted with acute non-ST elevation ACS were included in the study. Patients were divided into three groups based on the treatment strategy; Group 1: Those who underwent CAG; Group 2: Refused; and Group 3: Deemed unsuitable for procedure due to severe comorbidities. The primary outcomes were to assess the patient refusal rate and its impact on all-cause mortality. Results: The study included 201 elderly patients. Eighty-two (41%) patients did not undergo CAG and of those, 48 (24%) had severe comorbidities, and 34 (17%) refused the procedure. The in-hospital mortality for patients who underwent, refused, or could not undergo CAG was 5.0%, 0%, and 16.7% (p<0.01); 30-day mortality 8.5%, 9.1%, and 25% (p=0.01); and long-term mortality was 20.2%, 35.3%, and 47.9% (p<0.01), respectively. The median follow-up was 12 months. Hazard ratio of treatment refusal for long-term mortality was 1.97 (1.02-3.87, 95% CI). Conclusion: Substantial number of elderly patients with ACS refuses to undergo CAG and this leads to increased mortality. Factors affecting patient behavior and the decision-making process should be explored.