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CLINICAL RESEARCH: ACUTE CORONARY SYNDROMES

Advanced Age, Antithrombotic Strategy, and Bleeding in Non–ST-Segment Elevation Acute Coronary Syndromes

Results From the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) Trial

Renato D. Lopes, MD, PhD^_*,_*, Karen P. Alexander, MD^_*, Steven V. Manoukian, MD, Michel E. Bertrand, MD, Frederick Feit, MD, Harvey D. White, MD^||, Charles V. Pollack, Jr, MD, MA^¶, James Hoekstra, MD^#, Bernard J. Gersh, MB, ChB, DPhil^_**, Gregg W. Stone, MD and E. Magnus Ohman, MD^_*

^_* Duke University Medical Center, Durham, North Carolina
The Sarah Cannon Research Institute and Centennial Heart Center, Nashville, Tennessee
Hopital Cardiologique, Lille, France
New York University School of Medicine, New York, New York
^|| Auckland City Hospital, Auckland, New Zealand
^¶ Pennsylvania Hospital, Philadelphia, Pennsylvania
^# Wake Forest University, Winston-Salem, North Carolina
^_** Mayo Clinic, Rochester, Minnesota
Columbia University Medical Center, and The Cardiovascular Research Foundation, New York, New York

Manuscript received September 30, 2008; revised manuscript received December 9, 2008, accepted December 16, 2008.

^_* Reprint requests and correspondence: Dr. Renato D. Lopes, Box 3850, 2400 Pratt Street, Room 0311, Terrace Level, Durham, North Carolina 27705 (Email: renato.lopes{at}duke.edu).

Objectives: This study sought to evaluate the impact of age on outcomes in patients with moderate- and high-risk non–ST-segment elevation acute coronary syndrome (NSTE-ACS) enrolled in the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial.

Background: Aging-associated changes in physiology and metabolism may alter the risk and benefit of therapeutic strategies from that observed in younger people.

Methods: We performed a pre-specified analysis of 30-day and 1-year outcomes in 4 age groups, overall and among those undergoing percutaneous coronary intervention (PCI).

Results: Of 13,819 patients in the ACUITY trial, 3,655 (26.4%) were <55 years of age, 3,940 (28.5%) were 55 to 64 years of age, 3,783 (27.4%) were 65 to 74 years of age, and 2,441 (17.7%) were 75 years of age. Older patients had more cardiovascular risk factors and had a higher acuity at presentation. Patients age 75 years treated with bivalirudin alone had similar ischemic outcomes, but significantly lower rates of bleeding compared with those treated with heparin and glycoprotein IIb/IIIa inhibitors overall and in the PCI subset. The number needed to treat with bivalirudin alone to avoid 1 major bleeding event was lower in this age group (23 overall and 16 for PCI-treated patients) than in any other.

Conclusions: Ischemic and bleeding complications after NSTE-ACS increase with age. Although ischemic event rates are not statistically different with either bivalirudin alone or a heparin plus glycoprotein IIb/IIIa inhibitor, bleeding complications are significantly less frequent with bivalirudin alone. Because of the substantial risk of bleeding in patients age 75 years, the number needed to treat to avoid 1 major bleeding event using bivalirudin alone was the lowest in the elderly group, especially among those undergoing PCI. (Comparison of Angiomax Versus Heparin in Acute Coronary Syndromes [ACS]; NCT00093158)

Key Words: non–ST-segment elevation MI • age • heparin • bivalirudin

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   CABG = coronary artery bypass graft   GP = glycoprotein   MI = myocardial infarction   NNT = number needed to treat   NSTE-ACS = non–ST-segment elevation acute coronary syndrome(s)   PCI = percutaneous coronary intervention   UFH = unfractionated heparin

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