Elsevier

The Lancet

Volume 353, Issue 9157, 20 March 1999, Pages 955-959
The Lancet

Articles
How should age affect management of acute myocardial infarction? A prospective cohort study

https://doi.org/10.1016/S0140-6736(98)07114-1Get rights and content

Summary

Background

About 75% of patients with acute myocardial infarction are older than 70 years, but patients in this age group are commonly treated less vigorously than younger patients. This differential treatment may partly reflect clinicians' misconceptions about the outlook of such patients, and the importance of age in clinical decisions. We examined how age does and should affect the management of patients and risk stratification in acute myocardial infarction.

Methods

In this prospective cohort study, we recruited 1225 consecutive patients admitted with acute myocardial infarction to a district general hospital in east London. The primary endpoint was death. We used tabulation and regression methods to analyse the association between age group and clinical variables.

Findings

Patients aged 70 years or older took a longer time to arrive in hospital and were less likely to receive thrombolysis or discharge β-blockers than patients younger than 60 years: odds ratio 0·63 (95% Cl 9·45–0·88) for thrombolysis and 0·25 (0·16–0·37) for β-blockade, adjusted for sex, diabetes, previous acute myocardial infarction, Q wave infarction, and left-ventricular failure. Left-ventricular failure was the strongest independent predictor of death within 1 year of infarction with a hazard ratio of 4·76 (3·53–6·43), adjusted for age, sex, diabetes, and Q wave infarction. Patients aged 70 years or older without left-ventricular failure had significantly better survival at 1 year after acute myocardial infarction than patients under 60 years with left-ventricular failure. 70·8% (62·2–78·2) of the older patients who survived to hospital discharge were still alive 3 years later.

Interpretation

Elderly patients with acute myocardial infarction were treated less vigorously than younger patients. The prognosis of acute myocardial infarction, however, was substantially affected by the development of left-ventricular failure and other clinical indices, such that many older patients had a better outlook than younger patients with adverse clinical factors. In planning risk-based management, consideration of age independently of clinical status is inappropriate.

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

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