Long-term outcomes after invasive management for older patients with non-ST-segment elevation myocardial infarction

Matthew T Roe, Shuang Li, Laine Thomas, Tracy Y Wang, Karen P Alexander, E Magnus Ohman, Eric D Peterson
Circulation. Cardiovascular Quality and Outcomes 2013 May 1, 6 (3): 323-32

BACKGROUND: Early invasive management is recommended for patients with non-ST-segment elevation myocardial infarction (MI), but the incidence of long-term outcomes after early catheterization among older patients and the relationship of revascularization procedures with outcomes in this population have not been described.

METHODS AND RESULTS: Using data from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) registry, we linked 19 336 older patients (≥65 years) with non-ST-segment elevation MI found to have significant coronary disease during catheterization and who survived through 30 days posthospital discharge to Medicare/Medicaid data. All-cause mortality, readmission for MI, readmission for stroke, and use of repeat revascularization procedures were tracked for a median of 1181 days. Outcome comparisons were stratified by use of percutaneous coronary intervention (PCI; n=11 766, 60.8%) or coronary artery bypass grafting (n=3515, 18.2%) performed during the index hospitalization and through 30 days postdischarge, as well as by medical management without revascularization (n=4055, 21.0%). During follow-up, ≈17% of patients underwent PCI (most commonly in patients initially treated with PCI), and only 3% of patients underwent coronary artery bypass grafting. Compared with an unadjusted long-term mortality cumulative incidence through 5 years of 50% in the medical management group, mortality was lower in the PCI group (33.5%; adjusted hazard ratio, 0.75; 95% confidence interval, 0.70-0.79) and lowest in the coronary artery bypass grafting group (24.2%; adjusted hazard ratio, 0.52; 95% confidence interval, 0.47-0.57; P<0.001 for 3-way comparisons). The unadjusted cumulative incidence of the composite of death, readmission for MI, or readmission for stroke at 5 years was 62.4%, 44.9%, and 33.0% for medical management, PCI, and coronary artery bypass grafting, respectively.

CONCLUSIONS: Older patients with non-ST-segment elevation MI with significant coronary disease face high long-term risks for mortality and nonfatal cardiovascular outcomes after early catheterization that differ by type of revascularization procedure performed. These findings can help guide the design of studies evaluating long-term therapies among elderly post-MI patients.

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