title: International variation in invasive care of the elderly with acute coronary syndromes.
abstract: OBJECTIVE
  To explore variations in invasive care of the elderly with acute coronary syndromes across international practice.
  
  
  RESULTS
  Using combined populations from the SYMPHONY and 2nd SYMPHONY trials, we describe 30-day cardiac catheterization in elderly (> or = 75 years; n = 1794) vs. younger patients (< 75 years; n = 14,043) after multivariable adjustment and by region of enrolment. The use of cardiac catheterization and revascularization were not protocol-specified. Elderly patients (median age 78 years) were more often female and more frequently had hypertension, diabetes, prior myocardial infarction, and prior coronary bypass surgery. Overall, they underwent less cardiac catheterization than younger patients [53 vs. 63%; adjusted OR 0.53 (0.46, 0.60)]. The absolute rate of cardiac catheterization in the elderly varied from 77% (vs. 91% in younger patients) in the US cohort to 27% (vs. 41% in younger patients) in the non-US cohort. Revascularization of elderly who underwent cardiac catheterization was also higher in US than non-US cohorts (71.3 vs. 53.6%). There was a significant interaction between the patient age and the use of catheterization across US and non-US regions of enrolment, as well as differences in the predictors of catheterization in the elderly. Despite these findings, after adjustment, 90-day rates of death and death or myocardial infarction (MI) were not significantly different in elderly who underwent catheterization compared with those who did not.
  
  
  CONCLUSIONS
  Although older age is universally predictive of lower use of cardiac catheterization, marked variation in catheterization of the elderly exists across international practice. Demonstrated differences in patterns of use suggest a lack of consensus regarding optimal use of an invasive strategy in the elderly.
authors.affiliation: Outcomes Research and Assessment Group, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27710, USA. karen.alexander@duke.edu
authors.forename: Karen P
authors.initials: KP
authors.lastname: Alexander
authors.forename: Laura Kristin
authors.initials: LK
authors.lastname: Newby
authors.forename: Manju V
authors.initials: MV
authors.lastname: Bhapkar
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.forename: Judith S
authors.initials: JS
authors.lastname: Hochman
authors.forename: Matthias E
authors.initials: ME
authors.lastname: Pfisterer
authors.forename: David J
authors.initials: DJ
authors.lastname: Moliterno
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
mesh_terms: D000208:Acute Disease; D000368:Aged; D006328:Cardiac Catheterization / Q000706:statistics & numerical data*; D003327:Coronary Disease / Q000175:diagnosis / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016896:Treatment Outcome