title: The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP).
abstract: OBJECTIVE
  Older people increasingly constitute a large proportion of the acute coronary syndrome (ACS) population. We examined the relationship of age with receipt of more intensive management and secondary prevention medicine. Then, the comparative association of intensive management (reperfusion/angiography) over a conservative strategy on time to death was investigated by age.
  
  
  RESULTS
  Using data from 155 818 patients in the national registry for ACS in England and Wales [the Myocardial Ischaemia National Audit Project (MINAP)], we found that older patients were incrementally less likely to receive secondary prevention medicines and intensive management for both ST-elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). In STEMI patients ≥85 years, 55% received reperfusion compared with 84% in those aged 18 to <65 [odds ratio 0.22 (95% CI 0.21, 0.24)]. Not receiving intensive management was associated with worse survival [mean follow-up 2.29 years (SD 1.42)] in all age groups (adjusted for sex, cardiovascular risk factors, co-morbidities, healthcare factors, and case severity), but there was an incremental reduction in survival benefit from intensive management with increasing age. In STEMI patients aged 18-64, 65-74, 75-84, and ≥85, adjusted hazard ratios (HRs) for all-cause mortality comparing conservative treatment to intensive management were 1.98 (1.78, 2.19), 1.65 (1.51, 1.80), 1.62 (1.52, 1.72), and 1.36 (1.27, 1.47), respectively. In NSTEMI patients, the respective HRs were 4.37 (4.00, 4.78), 3.76 (3.54, 3.99), 2.79 (2.67, 2.91), and 1.90 (1.77, 2.04).
  
  
  CONCLUSIONS
  We found an incremental reduction in the use of evidence-based therapies with increasing age using a national ACS registry cohort. While survival benefit from more intensive management reduced with older age, better survival was associated with intensive management at all ages highlighting the requirement to improve standard of care in older patients with ACS.
authors.affiliation: Department of Emergency Medicine,James Paget University Hospital, Lowestoft Road, Gorleston-on-Sea, Norfolk NR31 6LA, UK Department of Medicine, University of East Anglia, Norwich, UK justinzaman@nhs.net.
authors.forename: M Justin
authors.initials: MJ
authors.lastname: Zaman
authors.affiliation: Department of Medicine, University of East Anglia, Norwich, UK.
authors.forename: Susan
authors.initials: S
authors.lastname: Stirling
authors.affiliation: Department of Medicine, University of East Anglia, Norwich, UK.
authors.forename: Lee
authors.initials: L
authors.lastname: Shepstone
authors.affiliation: Norfolk and Norwich University Hospital and James Paget University Hospital, Norwich, UK.
authors.forename: Alisdair
authors.initials: A
authors.lastname: Ryding
authors.affiliation: Department of Medicine, University of East Anglia, Norwich, UK.
authors.forename: Marcus
authors.initials: M
authors.lastname: Flather
authors.affiliation: Department of Medicine, University of East Anglia, Norwich, UK.
authors.forename: Max
authors.initials: M
authors.lastname: Bachmann
authors.affiliation: Academic Centre for Applied Clinical and Translational Research into Ageing, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK.
authors.forename: Phyo Kyaw
authors.initials: PK
authors.lastname: Myint
mesh_terms: D054058:Acute Coronary Syndrome / Q000401:mortality / Q000628:therapy*; D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D017023:Coronary Angiography / Q000592:standards / Q000706:statistics & numerical data; D003422:Critical Care / Q000592:standards* / Q000706:statistics & numerical data; D003695:Delivery of Health Care / Q000592:standards / Q000706:statistics & numerical data; D004739:England / Q000453:epidemiology; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000517:prevention & control; D015425:Myocardial Reperfusion / Q000592:standards / Q000706:statistics & numerical data; D055502:Secondary Prevention / Q000592:standards* / Q000706:statistics & numerical data; D014852:Wales / Q000453:epidemiology; D055815:Young Adult
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors
keywords: Acute coronary syndrome; Age; Elderly; Prognosis