Clinical characteristics, treatment pattens, and in-hospital outcomes in nonagenarians with acute coronary syndrome: insight from the REVEIL-ACS registry

Background/Introduction Despite improved outcomes in the overall acute coronary syndrome (ACS) population, older patients still have worse prognoses than younger patients. Patients aged ≥90 years (nonagenarians) represent a rapidly growing but underexplored subgroup. These patients often have morbidities and limited therapeutic options, resulting in unfavorable outcomes. However, there is limited data on diagnostic strategies, therapeutic management, and in-hospital outcomes for nonagenarians with ACS. To address this gap, we conducted an analysis focusing on age-stratified outcomes, particularly among the oldest old. Purpose This study aimed to evaluate age-specific trends in in-hospital outcomes following ACS and to clarify the clinical characteristics, treatment patterns, and prognoses of nonagenarians compared to those of younger patients. Methods The REVEIL-ACS registry is an ongoing, multicenter, prospective study that enrolled consecutive patients undergoing emergency coronary angiography for ACS at 25 Japanese centers between January 2024 and March 2025. Eligible patients were divided into four age groups: 20–69, 70–79, 80–89, and 90–99 years. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE) during hospitalization. The secondary outcomes were in-hospital death and major bleeding events. We used a parametric g-formula to estimate the marginal probabilities of in-hospital outcomes across age groups. Results Of 2,071 eligible patients, 828 (40%) were aged 20–69, 585 (28%) were 70–79, 559 (27%) were 80–89, and 99 (4.8%) were 90–99 years. The prevalence of elevated cardiac troponin, non-ST elevation myocardial infarction, and left main and multivessel disease increased in the higher age groups, while the proportion of patients undergoing emergent percutaneous coronary intervention and receiving mechanical circulatory support was similar across age groups. Of 1,822 patients with available post-hospitalization outcomes, those in the higher age groups were more likely to have comorbidities, including hypertension, chronic kidney disease, heart failure, and anemia. Approximately 90% of nonagenarians had a high bleeding risk based on the ARC-HBR criteria. Adjusted probability of MACCE was 5.1% (95% CI, 3.2%–6.8%) in patients aged 20–69 years, 9.2% (95% CI, 7.1%–12%) % in 70–79 years, 11% (95% CI, 8.4%–14%) in 80–89 years, 20% (95% CI, 10%–30%) in 90–99 years (Figure 1). Adjusted in-hospital mortality was lowest in the patients aged 20–69 years and highest in those aged 90–99 years (Figure 2A). However, this age-related trend was not observed for the adjusted probabilities of major bleeding (Figure 2B). Conclusions Even in nonagenarians, invasive treatment was frequently performed without an increase in major bleeding events. However, the incidence of in-hospital MACCE remained disproportionately high, underscoring the need for personalized medical strategies for nonagenarians.Figure 1Figure 2