Insights From the Ischemic Heart Events Postacute Coronary Syndromes Trial
Insights From the Ischemic Heart Events Postacute Coronary Syndromes Trial
Background: Evidence-based medications (EBM) are underused in older patients despite potentially larger absolute benefits. Little is known about factors influencing prescribing in the elderly with acute coronary syndromes.
Methods: Among the 15904 patients from the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes (SYMPHONY) and second SYMPHONY trials, we examined the rates of use of EBM according to age (<75 or ≥ 75 years, and 3 subgroups of 5 year increments among patients ≥75 years).
Results: Ninety-day mortality increased with age (<75 years, 1.3%; ≥75 to <80 years, 4.4%; ≥80 to <85 years, 6.0%; ≥85 years, 9.6%). Compared with subjects <75 years (n = 14043), acute EBM use was lower among patients ≥75 years (n = 1794): aspirin (83% vs 85%), heparin (73% vs 78%), and ß-blockers (70% vs 76%). Similarly, discharge use of ß-blockers (69% vs 76%) and statins (28% vs 40%) was lower, although this was not the case for angiotensin-converting enzyme inhibitors (44% vs 41%). These patterns persisted among eligible patients. Beyond the age of 75 years, EBM use was not further influenced by age except for statins and angiotensin-converting enzyme inhibitors, which were used less frequently in those ≥85 years. Among patients aged ≥75 years, prediction for use of each EBM in multivariable modeling was modest (C indices, ~0.7); except for statins, increasing age did not predict lower EBM use.
Conclusions: Despite higher mortality risk, EBM use was lower among older patients even considering eligibility. Among those aged ≥75 years, age was no longer the major factor predicting EBM use. The modest C indices suggest other factors are associated with prescribing, underscoring the need for treatment algorithms and quality assurance measures in older patients.
The population of older patients (age ≥75 years) is growing and cardiovascular disease remains the major cause of mortality in this age group. In a recent report from the Valsartan In Acute Myocardial Infarction Trial in patients with heart failure and/or an ejection fraction <40% after acute myocardial infarction (MI), each 10-year increase in age was associated with an almost 50% increase in 3-year mortality. Because older patients are underrepresented in clinical trials, treatment decisions are often based on impression rather than evidence, influenced by the frequently occurring comorbidities and the possible side effects from therapies. There are also issues of "cost-effectiveness" and the relative value of "longevity" vs other priorities.
Previous studies have shown that the use of evidence-based medicines (EBM) among patients with acute coronary syndromes (ACS) is less frequent in older populations, despite potentially greater absolute benefit. Contraindications to different EBM are more common in the elderly, as recently shown in the Can Rapid RISK Stratification of Unstable Angina Patients Supress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) registry, but it is not clear that this fully explains the lower use of EBM. The Guidelines Applied in Practice (GAP) project recently reported that embedding treatment guidelines into practice was associated with improved outcome in the cohort of patients (average age of 76 years) with acute MI. Thus, it is important to understand the factors associated with use (or nonuse) of EBM in order to most effectively deploy quality improvement strategies.
In the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes (SYMPHONY) and second SYMPHONY trials, which had no upper age exclusion, the use of many EBM was lower in older patients and there was international variation in practice. In the current analyses from the SYMPHONY trials databases, we analyzed treatment eligibility to determine if prescription of EBM was indeed lower among eligible patients ≥75 years and whether prescription could be predicted by clinical factors including cardiac and noncardiac comorbidities and age.
Background: Evidence-based medications (EBM) are underused in older patients despite potentially larger absolute benefits. Little is known about factors influencing prescribing in the elderly with acute coronary syndromes.
Methods: Among the 15904 patients from the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes (SYMPHONY) and second SYMPHONY trials, we examined the rates of use of EBM according to age (<75 or ≥ 75 years, and 3 subgroups of 5 year increments among patients ≥75 years).
Results: Ninety-day mortality increased with age (<75 years, 1.3%; ≥75 to <80 years, 4.4%; ≥80 to <85 years, 6.0%; ≥85 years, 9.6%). Compared with subjects <75 years (n = 14043), acute EBM use was lower among patients ≥75 years (n = 1794): aspirin (83% vs 85%), heparin (73% vs 78%), and ß-blockers (70% vs 76%). Similarly, discharge use of ß-blockers (69% vs 76%) and statins (28% vs 40%) was lower, although this was not the case for angiotensin-converting enzyme inhibitors (44% vs 41%). These patterns persisted among eligible patients. Beyond the age of 75 years, EBM use was not further influenced by age except for statins and angiotensin-converting enzyme inhibitors, which were used less frequently in those ≥85 years. Among patients aged ≥75 years, prediction for use of each EBM in multivariable modeling was modest (C indices, ~0.7); except for statins, increasing age did not predict lower EBM use.
Conclusions: Despite higher mortality risk, EBM use was lower among older patients even considering eligibility. Among those aged ≥75 years, age was no longer the major factor predicting EBM use. The modest C indices suggest other factors are associated with prescribing, underscoring the need for treatment algorithms and quality assurance measures in older patients.
The population of older patients (age ≥75 years) is growing and cardiovascular disease remains the major cause of mortality in this age group. In a recent report from the Valsartan In Acute Myocardial Infarction Trial in patients with heart failure and/or an ejection fraction <40% after acute myocardial infarction (MI), each 10-year increase in age was associated with an almost 50% increase in 3-year mortality. Because older patients are underrepresented in clinical trials, treatment decisions are often based on impression rather than evidence, influenced by the frequently occurring comorbidities and the possible side effects from therapies. There are also issues of "cost-effectiveness" and the relative value of "longevity" vs other priorities.
Previous studies have shown that the use of evidence-based medicines (EBM) among patients with acute coronary syndromes (ACS) is less frequent in older populations, despite potentially greater absolute benefit. Contraindications to different EBM are more common in the elderly, as recently shown in the Can Rapid RISK Stratification of Unstable Angina Patients Supress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) registry, but it is not clear that this fully explains the lower use of EBM. The Guidelines Applied in Practice (GAP) project recently reported that embedding treatment guidelines into practice was associated with improved outcome in the cohort of patients (average age of 76 years) with acute MI. Thus, it is important to understand the factors associated with use (or nonuse) of EBM in order to most effectively deploy quality improvement strategies.
In the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes (SYMPHONY) and second SYMPHONY trials, which had no upper age exclusion, the use of many EBM was lower in older patients and there was international variation in practice. In the current analyses from the SYMPHONY trials databases, we analyzed treatment eligibility to determine if prescription of EBM was indeed lower among eligible patients ≥75 years and whether prescription could be predicted by clinical factors including cardiac and noncardiac comorbidities and age.