ArticlesHow should age affect management of acute myocardial infarction? A prospective cohort study
Introduction
Ischaemic heart disease, including acute myocardial infarction, is the most common cause of premature (age <70 years) death in the UK and many other developed countries. The incidence and mortality of this disease increase with age. In 1995, 74·4% of deaths from acute myocardial infarction in England and Wales occurred in people aged 70 years or older.1
In the clinical setting, there is evidence that treatment is often less vigorous in elderly people than in younger patients both in terms of acute intervention and secondary prevention.2, 3, 4, 5 This differential treatment may partly reflect a judgment of clinicians that outlook is poor and treatment less effective in elderly patients. Although age is an important prognostic factor for all-cause and cardiac-specific mortality after acute myocardial infarction, it is one of many clinical determinants of outcome.6, 7 The most significant prognostic factor is left-ventricular function after acute myocardial infarction.8, 9, 10 Moreover, randomised trials have shown clear benefits of a range of common interventions in old as well as young patients. Reduction of infarct size with thrombolysis, for example, improves survival in patients older than 70 years11, 12, 13, 14 and, indeed, the net benefit seems to increase incrementally with age up to 75 years.15, 16
Age is, of course, a relevant consideration in clinical management of acute myocardial infarction, but its importance should be secondary to other clinical factors. We examine issues that affect treatment decisions in elderly patients with acute myocardial infarction, with data from the follow-up of patients admitted to a district general hospital in east London.
Section snippets
Patients
The study population consisted of 1225 consecutive patients with acute myocardial infarction who were admitted to the coronary care unit of Newham General Hospital between 1988 and 1994. The diagnosis of myocardial infarction was based on any two of the following three criteria: typical chest pain; 0·1 mV ST elevation or greater in at least one standard or two precordial leads; and an increase in serum creatine kinase to 400 IU/L or more (upper limit of reference range is 200 IU/L).
Baseline
Presentation, treatment, and early complications (table 1)
The proportion of women increased with older age, and the proportion of patients who were Asian or black declined, which indicates the demographic characteristics of the local population. Women constitute a high proportion of old people, and the Asian and black populations are young compared with the white population.
The proportion of patients who had a diagnosis of hypertension showed a small, but non-significant downward trend with age. Diabetes was most common in the 60–69 years age group
Discussion
This study shows the variation by age in the presentation, treatment, and prognosis of 1225 consecutive patients admitted with acute myocardial infarction. Our study group was a typical infarct population dominated by male smokers and it accurately represented our local population. Our findings, particularly in relation to prognosis, are relevant to treatment decision.
There was a substantial decline with older age in the proportion of patients who received acute thrombolysis and in those who
References (23)
- et al.
A new coronary prognostic index
Lancet
(1969) - et al.
Risk stratification before thrombolytic therapy in patients with acute myocardial infarction
J Am Coll Cardiol
(1990) - et al.
Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction. Anglo-Scandinavian Study of Early Thrombolysis (ASSET)
Lancet
(1988) - et al.
Comparison of risk and patterns of practice in patients older and younger than 70 years with acute myocardial infarction in a two-year period (1987–1989)
Am J Cardiol
(1991) Mortality statistics. Cause. Series DH2 no 22
(1997)- et al.
Adherence to national guidelines for drug therapy of suspected acute myocardial infarction: evidence for undertreatment in women and the elderly
Arch Intern Med
(1996) - et al.
Analysis of the risk of stroke in 20 891 patients with acute myocardial infarction following thrombolytic and antithrombotic treatment
N Engl J Med
(1992) - et al.
Short and long term prognosis of acute myocardial infarction since introduction of thrombolysis
BMJ
(1993) - et al.
Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction: results from an international trial of 41,021 patients
Circulation
(1995) Risk stratification and survival after acute myocardial infarction
N Engl J Med
(1983)
Variables predictive of survival in patients with coronary disease: selection by univariate and multivariate analyses from clinical, electrocardiographic, exercise, arteriographic, and quantitative angiographic evaluations
Circulation
Cited by (126)
Age Differences in the Chief Complaint Associated With a First Acute Myocardial Infarction and Patient's Care-Seeking Behavior
2020, American Journal of MedicineTime to reperfusion in high-risk patients with myocardial infarction undergoing primary percutaneous coronary intervention
2019, Revista Portuguesa de CardiologiaAge representation in antiepileptic drug trials: A systematic review and meta-analysis
2018, Epilepsy ResearchCitation Excerpt :Our current study highlighted their common use in AED trials but they were not associated with of younger cohorts except for the exclusion of other neurological disorders. Older epileptic patients may be underrepresented from clinical trials as their condition might be less likely to be refractory to first line agents (Barakat et al., 1999). Failure to include older patients in clinical trials may stem from paramount difficulties occurring even before patients can be considered for research.
Prognostic Impact of Age and Hemoglobin in Acute ST-Segment Elevation Myocardial Infarction Treated With Reperfusion Therapy
2017, American Journal of Cardiology