Predictors of Long‐Term Survival of Individuals with Acute Coronary Syndrome Aged 90 and Older Admitted to a Tertiary Care Center

To the Editor: The elderly population is rapidly growing in the United States. It is estimated that, by 2020, there will be 2.6 million nonagenarians and 135,000 centenarians.1 Advanced age is a predictor of morbidity and mortality in hospitalized individuals, particularly in the setting of an acute coronary syndrome (ACS).2-4 Management guidelines in the care of individuals aged 90 and older are not clear because of difficulty enrolling these people in randomized clinical trials,5 but high procedural success and low in-hospital mortality was reported when treating elderly adults.6-9 This single-center retrospective study explored in-hospital and long-term outcomes of individuals aged 90 and older consecutively admitted to a tertiary medical center with a diagnosis of ACS. Individuals were excluded if they had sudden cardiac death with no hope of neurological recovery. In-hospital and 1-year follow-up data were collected from reviewing office and in-hospital medical records. The angiograms of individuals who underwent angiography were reviewed, and a cardiologist blinded to their outcomes determined their Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) score.10 Information was collected on demographic, clinical, procedural, and angiographic variables for all participants. Approval of the study was obtained from the hospital's institutional review board. The primary goal of the study was to describe in-hospital and long-term outcomes at 1-year follow-up, including cardiac mortality, total mortality, stroke, major bleeding (transfusion of ≥2 units of blood, drop in hemoglobin of ≥3 mg/dL), and acute renal failure (increase in creatinine of 0.5 mg/dL over baseline). One hundred nine individuals were included (33% male, mean age 93.5). ACS symptoms consisted of non-ST-elevation myocardial infarction (NSTEMI, 65.4%), unstable angina pectoris (UA, 23.9%), and STEMI (11.0%). There was a high prevalence of hypertension (80.7%), cerebrovascular disease (22.9%), renal insufficiency (33.0%), and valvular disease (18.3%). The overall SYNTAX score was moderately high (23.2). Eighty-six percent of lesions were de novo, requiring a mean of 3.5 stents per participant to treat. Forty-six participants (42.2%) had died by 1 year; nine died in the hospital (8 from cardiac, 1 from noncardiac causes). Seven of the eight (87.5%) who died from cardiac causes received conservative treatment, and one (12.5%) underwent percutaneous coronary intervention (PCI). Thirty-five (32.1%) participants were admitted to the intensive care unit and had an average length of stay of 6.1 days. Of those who underwent PCI, 18.8% of those who died were in acute renal failure, versus 3.2% of those who were discharged alive. Vascular complications occurred in 1.7% of those who underwent PCI, cardiac perforation with tamponade in 1.7%, and need for blood transfusion in 6.8%. Outpatient follow-up data were available for 90 of the 100 participants who were discharged from the hospital (90.0%). Thirty-seven (41.1%) died, 20 (54.1%) from cardiac causes. Univariate analysis showed that index systolic blood pressure (SBP) was lower in participants who died (121.6, vs 134.3 mmHg, P = .005), as was ejection fraction (41.7%, vs 50%). Participants who lived were significantly more likely to have undergone PCI (56.6%) than those who died (43.4%) (P = .05). Cox regression analysis showed that conservative treatment was associated with greater mortality than PCI (hazard ratio (HR) = 2.2, P = .04) (Figure 1) and higher SBP (HR = 0.98, P = .01) was an independent predictor of survival at 1-year follow-up. Conservative management was chosen because of dementia (4.6%), participant or family wishes (34.2%), physician's decision (13.0%), and nontreatable disease (4.6%). Nine of 109 (8.3%) participants died in the hospital, consistent with published data.7 One-year mortality in participants who underwent PCI was 28.6%. Participants who lived were significantly more likely to undergo PCI (56.6%) than those who died (43.4%) (p = .05). This is also consistent with data from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines registry,2 which found lower risk-adjusted mortality in individuals with NSTEMI treated using evidence-based guidelines including PCI, and the Global Registry of Acute Coronary Events,8 in which 6-month mortality was significantly lower in individuals with ACS treated with revascularization (odds ratio = 0.68, 95% confidence interval = 0.49–0.95). PCI in nonagenarians appear to be safe overall. Rates of adverse events are acceptable. Despite reports of more-complex disease in this population, PCI appears to be a predictor of better survival than conservative treatment. This study's retrospective design, it being conducted in a single center, and its small sample size limit this study. Abstract was presented at the American Heart Association Scientific Sessions 2014, Chicago, Illinois. Supported by the Nicolas and Gail Shammas Research Fund at the Midwest Cardiovascular Research Foundation and the Genesis Health System Research Fund, Davenport, Iowa. None of the authors have relevant conflict of interest to the research presented. Author Contributions: NW Shammas: concept, design, protocol writing, data monitoring, statistical analysis, manuscript writing. GA Shammas: data monitoring and auditing, data collection, oversee of the project conduct, data analysis, manuscript review and editing. M Jerin: statistical analysis, critical data review and monitoring, data analysis, manuscript review and editing. Shanks, Dvorak, Serrano, Harb, Voelliger: protocol concept and discussions, data acquisition, data tabulation, data analysis, manuscript review and editing. Sponsor's Role: None.