The severity paradox in ACS: comorbidities define outcomes, not age

Introduction and Purpose Despite advances in pharmacological and interventional treatments, acute coronary syndromes (ACS) remain a leading cause of death and high morbidity worldwide, particularly among the elderly. Due to age-related physiological changes, a greater burden of atherosclerosis, and a higher prevalence of cardiovascular and other comorbidities, elderly patients receive fewer guideline-recommended cardiovascular medications and invasive treatments. The aim of our observational study was to examine the baseline characteristics of our patients and intrahospital prognosis. Results We included 1036 consecutive patients aged 75 years or older (80.9±4.4) with ACS in our study. 488(47.1%) were female, and 548 were male (52.9%). Myocardial infarction with ST-segment elevation (STEMI) was diagnosed in 40.69% of patients; myocardial infarction without ST-segment elevation (NSTEMI) in 53.33%; and non-stable angina pectoris in 5.98%. Typical chest pain was present in 70.2% of patients. The average left ventricular ejection fraction (LVEF) was 46.24 ± 13.43%. The most common comorbidities were arterial hypertension (78.9%), dyslipidemia (44.9%), diabetes mellitus (35.8%), and chronic renal insufficiency (25%). 29.2% of patients previously experienced a myocardial infarction, 8.23% had a stroke, and 16.4% had a percutaneous coronary intervention (PCI). Angiography was performed in 62.7% of all included patients: 74.3% with STEMI, 54.4% with NSTEMI, and 50.9% with non-stable angina. 25.6% had multivessel coronary disease, and 6.37% had left main disease. PCI was performed in 320 patients. At discharge, 61.2% were on dual antiplatelet therapy and 69.1% on statins. Hospital stay was 5.57 ± 3.88 days. Laboratory parameters in Table 1. 178 (21.9%) patients died during hospitalization. Multivariable logistic regression analysis that included baseline clinical, laboratory, echocardiographic, and angiographic findings showed that independent predictors of intrahospital mortality were lower systolic blood pressure (OR = 0.99; p = 0.049), higher heart rate (OR = 1.01; p = 0.031), worse renal function, that is lower eGFR (OR = 0.97; p < 0.001), higher levels of C-reactive protein (OR = 1.01; p = 0.011) and higher glycemia at admission (OR = 1.11; p < 0.001). Conclusions Our patients had a high mortality rate; however, age was not associated with increased intrahospital mortality. Laboratory parameters at admission, suggesting the presence of uncontrolled comorbidities (diabetes, renal insufficiency, inflammation) and hemodynamic markers, were better predictors of mortality. This suggests that chronological age merely indicates the accumulated burden of comorbidities rather than being an independent factor influencing outcomes. Despite guideline recommendations, patients received suboptimal acute and chronic management, with PCI performed only in a third of patients and suboptimal antiplatelet and statin therapy at discharge.