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CLINICAL RESEARCH: CORONARY ARTERY DISEASE

Characteristics, Management, and Outcomes of 5,557 Patients Age 90 Years With Acute Coronary Syndromes

Results From the CRUSADE Initiative

Adam H. Skolnick, MD^_*, Karen P. Alexander, MD, Anita Y. Chen, MS, Matthew T. Roe, MD, MSH, Charles V. Pollack, Jr, MD, MA, E. Magnus Ohman, MD, John S. Rumsfeld, MD, PhD, W. Brian Gibler, MD^||, Eric D. Peterson, MD, MPH and David J. Cohen, MD, MSc^_*,¶,_*

^_* Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania
Denver VA Medical Center/University of Colorado, Denver, Colorado
^|| University of Cincinnati College of Medicine, Cincinnati, Ohio
^¶ Saint Luke's Mid America Heart Institute, Kansas City, Missouri

Manuscript received July 14, 2006; revised manuscript received January 5, 2007, accepted January 5, 2007.

^_* Reprint requests and correspondence: Dr. David J. Cohen, Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, Missouri 64111 (Email: dcohen{at}saint-lukes.org).

Objectives: The goal of this work was to explore the treatment and outcomes of patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) age 90 years.

Background: The elderly are often excluded from clinical trials of NSTE-ACS and are underrepresented in clinical registries.

Methods: We used data from the CRUSADE registry to study 5,557 patients with NSTE-ACS age 90 years and compared their baseline characteristics, treatment patterns, and in-hospital outcomes with a cohort age 75 to 89 years (n = 46,270).

Results: Although both groups had much in common, compared with the younger elderly, the older elderly were less likely to be diabetic, smokers, or obese. Among patients without contraindications, the older elderly were less likely to receive glycoprotein IIb/IIIa inhibitors and statins during the first 24 h and were less likely to undergo cardiac catheterization within 48 h. The older elderly were more likely to die (12.0% vs. 7.8%) and experienced more frequent adverse events (26.8% vs. 21.3%) during the hospitalization—differences that persisted after adjustment for baseline patient and hospital characteristics. Increasing adherence to guideline-recommended therapies was associated with both increased bleeding and a graded reduction in risk-adjusted in-hospital mortality across both age groups.

Conclusions: In this large population of nonagenarians and centenarians with NSTE-ACS, increasing adherence to guideline-recommended therapies was associated with decreased mortality. These findings reinforce the importance of optimizing care patterns for even the oldest patients with NSTE-ACS, while examining novel approaches to reduce the risk of bleeding in this rapidly expanding patient population.

Abbreviations and Acronyms   CI = confidence interval   NSTE-ACS = non–ST-segment elevation acute coronary syndromes   OR = odds ratio

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