SEARCH

SEARCH BY CITATION

Keywords:

  • elders;
  • aged;
  • over 75;
  • acute coronary syndromes;
  • diagnosis;
  • outcomes

Abstract

  1. Top of page
  2. Abstract
  3. References

ObjectivesTo describe the evaluation and outcomes of elder patients with suspected acute coronary syndromes (ACS) presenting to the emergency department (ED).

MethodsThis was a post hoc analysis of the Internet Tracking Registry for Acute Coronary Syndromes (itrACS) registry, which had 17,713 ED visits for suspected ACS. First visits from the United States with nonmissing patient demographics, 12-lead electrocardiogram results, and clinical history were included in the analysis. Those who used cocaine or amphetamines or left the ED against medical advice were excluded. Elder was defined as age 75 years or older. ACS was defined by 30-day revascularization, Diagnosis-related Group codes, or death within 30 days with positive cardiac biomarkers at index hospitalization. Multivariable logistic regression analyses were performed to determine the association between being elder and 1) 30-day all-cause mortality, 2) ACS, 3) diagnostic tests ordered, and 4) disposition. Multivariable logistic regression was also performed to determine which clinical variables were associated with ACS in elder and nonelder patients.

ResultsA total of 10,126 patients with suspected ACS presenting to the ED were analyzed. For patients presenting to the ED, being elder was independently associated with ACS and all-cause 30-day mortality, with adjusted odds ratios of 1.8 (95% confidence interval [CI] = 1.5 to 2.2) and 2.6 (95% CI = 1.6 to 4.3), respectively. Elder patients were more likely to be admitted to the hospital (adjusted odds ratio, 2.2; 95% CI = 1.8 to 2.6), but there were no differences in the rates of cardiac catheterization and noninvasive stress cardiac imaging. Different clinical variables were associated with ACS in elder and nonelder patients. Chest pain as chief complaint, typical chest pain, and previous history of coronary artery disease were significantly associated with ACS in nonelder patients but were not associated with ACS in elder patients. Male gender and left arm pain were associated with ACS in both elder and nonelder patients.

ConclusionsElder patients who present to the ED with suspected ACS represent a population at high risk for ACS and 30-day mortality. Elders are more likely to be admitted to the hospital, but despite an increased risk for adverse events, they have similar odds of receiving a diagnostic test, such as stress cardiac imaging or cardiac catheterization, compared with nonelder patients. Different clinical variables are associated with ACS, and clinical prediction rules utilizing presenting symptoms should consider the effect modification of age.

References

  1. Top of page
  2. Abstract
  3. References
  • Goldberg RJ, Gore JM, Gurwitz JH, et al. The impact of age on the incidence and prognosis of initial acute myocardial infarction: the Worcester Heart Attack Study Am Heart J 1989;117:543549.
  • Stone PH, Thompson B, Anderson HV, et al. Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: the TIMI III registry JAMA 1996;275:11041112.
  • Lindsay J, Reddy VM, Pinnow EE, Little T, Pichard AD. Morbidity and mortality rates in elderly patients undergoing percutaneous coronary transluminal angioplasty Am Heart J 1994;128:697702.
  • Hasdai D, Holmes Jr. DR, Criger DA, Topol EJ, Califf RM, Harrington RA. Age and outcome after acute coronary syndromes without persistent ST-segment elevation Am Heart J 2000;139:858866.
  • Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain JAMA 2000;283:32233229.
  • Sloan FA, Trogdon JG, Curtis LH Schulman KA. The effect of dementia on outcomes and process of care for Medicare beneficiaries admitted with acute myocardial infarction J Am Geriatr Soc 2004;52:173181.
  • McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary Adv Data 2004:134.
  • He W, Sengupta M, Velkoff VA, et al. U.S. Census Bureau, Current Population Reports, P23-209, 65+ in the United States: 2005 Washington , DC : U.S. Government Printing Office; 2005.
  • Graham MM, Ghali WA, Faris PD, et al. Survival after coronary revascularization in the elderly Circulation 2002;105:23782384.
  • Giugliano RP, Camargo A Baum, A, Lloyd-Jones, DM et al. Elderly patients receive less aggressive medical and invasive management of unstable angina: potential impact of practice guidelines Arch Intern Med 1998;158:11131120.
  • Bach RG, Cannon CP, Weintraub WS, et al. The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes Ann Intern Med 2004;141:186195.
  • Munoz JC, Alonso JJ, Duran JM, et al. Coronary stent implantation in patients older than 75 years of age: clinical profile and initial and long-term (3 years) outcome Am Heart J 2002;143:620626.
  • De Servi S, Cavallini C, Dellavalle A, et al. Non-ST-elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome Am Heart J 2004;147:830836.
  • Morrison DA, Bies RD, Sacks J. Coronary angioplasty for elderly patients with “high risk” unstable angina: short-term outcomes and long-term survival J Am Coll Cardiol 1997;29:339344.
  • Thompson RC, Holmes Jr. DR, Grill DE, Mock MB, Bailey KR. Changing outcome of angioplasty in the elderly J Am Coll Cardiol 1996;27:814.
  • Magid DJ, Masoudi FA, Vinson DR, et al. Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients Ann Emerg Med 2005;46:1421.
  • Liistro F, Angioli P, Falsini G, et al. Early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome: comparison with younger patients regarding 30 day and long term outcome Heart 2005;91:12841288.
  • Alexander KP, Roe MT, Chen AY, et al. Evolution in cardiovascular care for elderly patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative J Am Coll Cardiol 2005;46:14791487.
  • Rathore SS, Mehta RH, Wang Y, Radford MJ, Krumholz HM. Effects of age on the quality of care provided to older patients with acute myocardial infarction Am J Med 2003;114:307315.
  • Bayer AJ. Presentation and management of myocardial infarction in the elderly Br J Hosp Med 1988;40 3001, 304–6.
  • Bayer AJ, Chadha JS, Farag RR Pathy MS. Changing presentation of myocardial infarction with increasing old age J Am Geriatr Soc 1986;34:263266.
  • Solomon CG, Lee TH, Cook EF, et al. Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: the Multicenter Chest Pain Study experience Am J Cardiol 1989;63:772776.
  • Lindsell CJ, Anantharaman V, Diercks D et al. The Internet Tracking Registry of Acute Coronary Syndromes (itr ACS): a multicenter registry of patients with suspicion of acute coronary syndromes reported using the standardized reporting guidelines for emergency department chest pain studies Ann Emerg Med 2006;48:666677.
  • Miller CD, Lindsell CJ, Anantharaman V, et al. Performance of a population-based cardiac risk stratification tool in Asian patients with chest pain Acad Emerg Med 2005;12:423430.
  • Anonymous. Myocardial infarction redefined—a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction Eur Heart J 2000;21:15021513.
  • Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients with Unstable Angina) J Am Coll Cardiol 2002;40:13661374.
  • Han JH, Lindsell CJ, Storrow AB, et al. The role of cardiac risk factor burden in diagnosing acute coronary syndromes in the emergency department setting Ann Emerg Med 2007;49:145152.
  • Jayes RL, Beshansky JR, D'Agostino RB Selker HP. Do patients' coronary risk factor reports predict acute cardiac ischemia in the emergency department? A multicenter study J Clin Epidemiol 1992;45:621626.
  • Arnold AM, Psaty BM, Kuller LH, et al. Incidence of cardiovascular disease in older Americans: the cardiovascular health study J Am Geriatr Soc 2005;53:211218.
  • Selker HP, Beshansky JR, Griffith JL, et al. Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial Ann Intern Med 1998;129:845855.
  • Baxt WG, Shofer FS, Sites FD Hollander JE. A neural network aid for the early diagnosis of cardiac ischemia in patients presenting to the emergency department with chest pain Ann Emerg Med 2002;40:575583.
  • Tresch DD, Brady WJ, Aufderheide TP, Lawrence SW, Williams KJ. Comparison of elderly and younger patients with out-of-hospital chest pain. Clinical characteristics, acute myocardial infarction, therapy, and outcomes Arch Intern Med 1996;156:10891093.
  • Soiza RL, Leslie SJ, Harrild K, Peden NR, Hargreaves AD. Age-dependent differences in presentation, risk factor profile, and outcome of suspected acute coronary syndrome J Am Geriatr Soc 2005;53:19611965.
  • Moore AR, Clinch D. Underlying mechanisms of impaired visceral pain perception in older people J Am Geriatr Soc 2004;52:132136.
  • Pilote L, Miller DP, Califf RM, Rao JS, Weaver WD, Topol EJ. Determinants of the use of coronary angiography and revascularization after thrombolysis for acute myocardial infarction N Engl J Med 1996;335:11981205.
  • Avezum A, Makdisse M, Spencer F, et al. Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE) Am Heart J 2005;149:6773.
  • Han JH, Miller KF, Storrow AB. Factors affecting cardiac catheterization rates in elderly patients with acute coronary syndromes Acad Emerg Med 2007;14:228233.
  • Ambepitiya G, Roberts M, Ranjadayalan K Tallis R. Silent exertional myocardial ischemia in the elderly: a quantitative analysis of anginal perceptual threshold and the influence of autonomic function J Am Geriatr Soc 1994;42:732737.
  • Milner KA, Funk M, Richards S, Vaccarino V, Krumholz HM. Symptom predictors of acute coronary syndromes in younger and older patients Nurs Res 2001;50:233241.
  • Cooper RJ. Misleading negative chest radiographs: should we ADHERE to the conclusions? Ann Emerg Med 2006;47:1921.