title: Decreased usage and increased effectiveness of percutaneous coronary intervention in complex older patients with acute coronary syndromes.
abstract: BACKGROUND
  Application of percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) is suboptimal in older frail individuals. This study was conducted to verify if background risk is a risk factor for underuse and diminished effectiveness of PCI in older patients.
  
  
  METHODS
  An observational cohort study was conducted using data from the Acute Myocardial Infarction in Florence 2 registry, including all ACS hospitalised in 1 year in the area of Florence, Italy. Patients aged 75+ years were selected, whose background risk was stratified with the Silver Code (SC), a validated tool predicting mortality based upon administrative data. Multivariable OR for PCI application and HR for 1-year mortality by PCI usage were calculated.
  
  
  RESULTS
  In 698 patients (358 women, mean age 83 years), of whom 176 had ST-segment elevation myocardial infarction (STEMI), for each point increase in SC score the odds for application of PCI decreased by 11%, whereas the hazard of 1-year mortality increased by 10%, adjusting for positive and negative predictors. PCI reduced 1-year mortality progressively more with increasing SC, with HR (95% CI) of 0.8 (0.19 to 1.21), 0.41 (0.18 to 0.45), 0.41 (0.23 to 0.74) and 0.26 (0.14 to 0.48) for SC of 0-3, 4-6, 7-10 and 11+.
  
  
  CONCLUSIONS
  Application of PCI in older ACS patients decreased with increasing background risk. This therapeutic attitude could not be justified by decreasing effectiveness of PCI in more compromised patients: conversely, application of PCI was associated with a long-term survival advantage that increased progressively with background risk, as expressed by SC.
authors.affiliation: Department of Experimental and Clinical Medicine, Research Unit of Medicine of Aging, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Di Bari
authors.affiliation: Epidemiology Unit, Local Health Unit 10, Florence, Italy.
authors.forename: Daniela
authors.initials: D
authors.lastname: Balzi
authors.affiliation: Department of Experimental and Clinical Medicine, Research Unit of Medicine of Aging, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
authors.forename: Stefania
authors.initials: S
authors.lastname: Fracchia
authors.affiliation: Epidemiology Unit, Local Health Unit 10, Florence, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Barchielli
authors.affiliation: Department of Experimental and Clinical Medicine, Research Unit of Medicine of Aging, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Orso
authors.affiliation: Department of Cardiovascular Medicine, Unit of Internal Medicine and Cardiology, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Sori
authors.affiliation: Cardiology Unit, Santa Maria Nuova Hospital, Local Health Unit 10, Florence, Italy.
authors.forename: Simona
authors.initials: S
authors.lastname: Spini
authors.affiliation: Department of Cardiovascular Medicine, Cardiology Unit 1, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
authors.forename: Nazario
authors.initials: N
authors.lastname: Carrabba
authors.affiliation: Cardiology Unit, Nuovo San Giovanni di Dio Hospital, Local Health Unit 10, Florence, Italy.
authors.forename: Giovanni M
authors.initials: GM
authors.lastname: Santoro
authors.affiliation: Department of Experimental and Clinical Medicine, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Fondazione Don Carlo Gnocchi IRCCS, Florence Italy.
authors.forename: Gian Franco
authors.initials: GF
authors.lastname: Gensini
authors.affiliation: Department of Experimental and Clinical Medicine, Research Unit of Medicine of Aging, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
authors.forename: Niccolò
authors.initials: N
authors.lastname: Marchionni
mesh_terms: D017668:Age of Onset; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D010043:Outcome and Process Assessment, Health Care; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends; D020379:Risk Adjustment / Q000706:statistics & numerical data / Q000639:trends; D018570:Risk Assessment / Q000592:standards; D012307:Risk Factors; D016019:Survival Analysis
keywords: Coronary Artery Disease; Quality of Care and Outcomes