title: Association of increasing age with receipt of specialist care and long-term mortality in patients with non-ST elevation myocardial infarction.
abstract: BACKGROUND
  observational studies suggest that older patients are less likely to receive secondary prevention medicines following acute coronary syndrome (ACS).
  
  
  OBJECTIVE
  to examine the association of increasing age with receipt of specialist care and influence of specialist care on long-term mortality in patients with non-ST elevation myocardial infarction (NSTEMI).
  
  
  METHODS
  a cohort study.
  
  
  METHODS
  National ACS registry of England and Wales.
  
  
  METHODS
  a total of 85,183 patients admitted with NSTEMI between 2006 and 2010.
  
  
  METHODS
  logistic regression analyses to assess receipt of secondary prevention medicines (ACE inhibitor, β-blocker, statin, aspirin) by age group; multivariate Cox regression models to examine longitudinal effect of cardiologist care on all-cause mortality by age group.
  
  
  RESULTS
  mean age 72.0 years (SD 13.0 years), mean follow-up was 2.13 years. Older patients received less cardiologist care (70.2% of NSTEMI patients ≥85 years compared with 94.7% of patients <65) years and had more co-morbidity. Cardiologists prescribed more secondary prevention in all age groups than generalists, but this was mostly explained away by co-morbidity (receipt of statin crude OR 1.51 (1.27,1.80), fully adjusted OR 1.11 (0.92,1.33) in patients ≥85 years). Receiving cardiologist care compared with generalist care was associated with a decreased risk of death in all even after adjustment for co-morbidity, disease severity and secondary prevention; this benefit reduced incrementally with older age group (adjusted hazard ratio (HR) 0.58 (0.49,0.68) aged <65; 0.87 (0.82,0.92) aged ≥85).
  
  
  CONCLUSIONS
  older patients with NSTEMI were less likely to see a cardiologist, but reduced treatment by generalists was explained away by co-morbidity. Cardiologist care was associated with lower mortality in all age groups than a generalist, but this survival benefit was less pronounced in older patients.
authors.affiliation: Medicine, James Paget University Hospital, Great Yarmouth, Norfolk NR31 6LA, UK Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK.
authors.forename: M Justin
authors.initials: MJ
authors.lastname: Zaman
authors.affiliation: Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK.
authors.forename: Robert
authors.initials: R
authors.lastname: Fleetcroft
authors.affiliation: Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK.
authors.forename: Max
authors.initials: M
authors.lastname: Bachmann
authors.affiliation: Medicine, James Paget University Hospital, Great Yarmouth, Norfolk NR31 6LA, UK Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK.
authors.forename: Toomas
authors.initials: T
authors.lastname: Sarev
authors.affiliation: Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK.
authors.forename: Susan
authors.initials: S
authors.lastname: Stirling
authors.affiliation: Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, Norfolk, UK.
authors.forename: Allan
authors.initials: A
authors.lastname: Clark
authors.affiliation: School of Medicine and Dentistry, University of Aberdeen, Aberdeen AB25 2ZD, UK.
authors.forename: Phyo Kyaw
authors.initials: PK
authors.lastname: Myint
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use; D002309:Cardiology; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D015897:Comorbidity; D003695:Delivery of Health Care; D004739:England; D005260:Female; D058006:General Practice; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D016015:Logistic Models; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis / Q000517:prevention & control / Q000628:therapy*; D016017:Odds Ratio; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D012042:Registries; D012307:Risk Factors; D055502:Secondary Prevention; D013038:Specialization; D013997:Time Factors; D016896:Treatment Outcome; D014852:Wales
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D002317:Cardiovascular Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D001241:Aspirin
keywords: acute coronary syndrome; older people; quality of health care; survival