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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 5, September/October 2020
252
AFRICA
Effect of invasive strategy on long-term mortality in
elderly patients presenting with acute coronary syndrome
Samet Yilmaz, Mehmet Koray Adali, Oguz Kilic, Aysen Til, Yalin Tolga Yaylali
Abstract
Objective:
The elderly have the highest incidence of cardio-
vascular disease and frequently present with acute coronary
syndrome (ACS). In this study, our aim was to evaluate
the effect of an invasive strategy on long-term mortality in
patients of 80 years and older presenting with ACS.
Methods:
Patients who were admitted to hospital with ACS
were recruited using appropriate ICD codes in the comput-
erised hospital data system. After exclusion of patients below
80 years old, the remaining 156 patients were involved in the
final analyses. Ninety-four of 156 patients (60.3%) underwent
coronary angiography and they constituted the invasive-
strategy group, whereas the remaining 62 (39.7%) patients
were treated medically and they constituted the conservative-
strategy group.
Results:
Median follow-up duration of patients was 8.5 (0–61)
months. Total mortality at the end of the follow-up period
was 24 (25.5%) patients in the invasive-strategy group and
30 (48.4%) in the conservative-strategy group (
p
=
0.006).
According to Cox regression analysis, the invasive strategy
(OR: 0.26, 95% CI: 0.12–0.56, p
=
0.001), presentation with
ST-segment elevation myocardial infarction (OR: 7.76, 95%
CI: 1.74–34.57, p
=
0.002), low ejection fraction below 40%
(OR: 3.11, 95% CI: 1.43–6.76,
p
=
0.004), heart rate (OR:
0.98, 95% CI: 0.96–0.99, p
=
0.013) and GRACE risk score
between 150 and 170 (OR: 7.76, 95% CI: 1.74–34.57,
p
=
0.002) were related to long-term mortality.
Conclusions:
Our results show the benefit of the invasive strat-
egy on mortality rate in elderly patients over 80 years old and
presenting with ACS.
Keywords:
elderly, acute coronary syndrome, mortality
SSubmitted 21/8/19, accepted 24/5/20
Published online 22/6/20
Cardiovasc J Afr
2020;
31
: 252–256
www.cvja.co.zaDOI: 10.5830/CVJA-2020-011
With the aging of societies, the elderly population is increasing.
Acute coronary syndrome (ACS) is not only the causative factor
for mortality in younger people but is also one of the major
causes of death in elderly people.
1
Coronary atherosclerosis is
a dynamic process and progresses over time, so aging is a well-
known risk factor for coronary artery disease.
Patients over 80 years account for more than one-third of
those presenting with ACS and for more than 50% of in-hospital
mortality due to ACS.
2
However, randomised, controlled trials
have given less importance to elderly patients. For example, in the
TRITON-TIMI 38 study, 13% of the patients and in the PLATO
study, 15% of the patients were over the age of 75 years.
3,4
Therefore
scientific evidence concerning elderly patients in ACS is scarce.
There are no specific guidelines concerning the treatment of
elderly patients, hence the treatment strategy is not clear in this
population.
5
Elderly patients diagnosed with ACS represent a
high-risk population and therefore they should be treated more
aggressively.
Over the last decade, an almost linear decrease in rates
of mortality after ACS has been reported in all age classes,
including the very elderly, in association with both the increased
use of early percutaneous coronary intervention (PCI) and
recommended medications.
6
Registry data from Europe showed
that, over the last 15 years, the progressive switch from a
conservative treatment to a more invasive approach may have
contributed to reduction in mortality rates across the ACS
spectrum, irrespective of age and gender.
7,8
In this trial, our aim was to demonstrate the effect of the
invasive strategy on long-term mortality rates in patients 80 years
and older presenting with ACS.
Methods
Patients who were hospitalised due to a diagnosis of ACS
between August 2014 and October 2017 were retrospectively
screened for this trial. Patients who were admitted to hospital
with ST-segment elevation myocardial infarction (STEMI),
non-ST segment elevation myocardial infarction (NSTEMI) and
unstable angina pectoris (USAP) were selected using appropriate
ICD codes in the computerised hospital data system. After the
exclusion of patients below 80 years, the remaining 156 patients
were involved in the final analyses.
This study was in compliance with the principles outlined in
the Declaration of Helsinki. It was approved by the local ethics
committee.
STEMI was defined by characteristic symptoms of myocardial
ischaemia in association with persistent electrocardiographic
ST elevation and the subsequent release of biomarkers of
myocardial necrosis. Diagnostic ST elevation in the absence of
left ventricular (LV) hypertrophy or left bundle branch block
is defined by the European Society of Cardiology/American
Heart Association/World Heart Federation Task Force as is the
Cardiology Department, Pamukkale University Hospitals,
Pamukkale, Denizli, Turkey
Samet Yilmaz, MD,
sametyilmazmd@gmail.comMehmet Koray Adali, MD
Oguz Kilic, MD
Yalın Tolga Yaylali, MD
Public Health Department, Pamukkale University,
Pamukkale, Denizli, Turkey
Aysen Til, MD