Archives of Cardiovascular Disease (2008) 101, 449—458 View metadata, citation and similar papers at core.ac.uk brought to you by CORE Disponible en ligne sur www.sciencedirect.com provided by Elsevier - Publisher Connector CLINICAL RESEARCH Are there specific prognostic factors for acute coronary syndrome in patients over 80 years of age? Les facteurs pronostiques des syndromes coronariens aigus sont-ils spécifiques chez les sujets âgés de plus de 80 ans ? Julien Austruy, Mohamed El Bayomy, Cecile Baixas 1, Meyer Elbaz, Olivier Lairez, Nicolas Dumonteil, Nicolas Boudou, Didier Carrié, Pascal Degroote 1, Michel Galinier ∗,1 Pôle cardiovasculaire et métabolique, CHU Rangueil, TSA 50032, 31509 Toulouse cedex, France Received 24 February 2008; received in revised form 18 May 2008; accepted 20 May 2008 Available online 28 August 2008 KEYWORDS Summary Acute coronary Purpose. — In elderly patients, the prognosis of acute coronary syndrome is bleak and the impact syndrome; of geriatric factors is as yet unknown. The purpose of this work was to identify factors predictive Elderly; of poor outcome at Month 6 in a population of elderly subjects admitted into hospital with acute Geriatrics; coronary syndrome. Mortality; Materials and methods. — One hundred and thirty-two patients over 80 years of age were com- Major cardiac and pared with 127 patients under 80, all admitted into a cardiology intensive care unit with cerebrovascular acute coronary syndrome between May 2006 and January 2007, vis-à-vis outcome, mortality events and cardiovascular events, both during the hospital stay and six months later. Results. — Coronary angiography was performed in fewer of the over-80 group (85.6% versus 97.7%, p < 0.001) but revascularisation rates were comparable in both groups (75.6% versus 78.9%, p = 0.58). During the hospital stay, the incidence of complications was higher (68.8% versus 38.1%, p < 0.0001) in the older patients as was mortality (18.2% versus 3.2%, p = 0.0001). At Month 6, all-cause mortality was higher in the octogenarians (28.0% versus 10.6%, p < 0.001). The independent variables associated with Month 6 all-cause mortality in the over-80 group ∗ Corresponding author. E-mail address: [email protected] (M. Galinier). 1 Cardiogeriatrics Working Group, Société Franc¸aise de Cardiologie (French Cardiology Society), Société Franc¸aise de Gériatrie et de Gérontologie (French Geriatrics and Gerontology Society), France. 1875-2136/$ — see front matter © 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.acvd.2008.05.008 450 J. Austruy et al. were: systolic blood pressure of less than 100 mmHg, an admission heart rate of over 100 bpm, a history of cardiovascular disease, acute coronary syndrome with ST segment elevation in the anterior territory, and the absence of chest pain. Conclusion. — In elderly patients admitted into hospital with acute coronary syndrome, geriatric parameters do not seem to affect prognosis which is dominated by cardiac variables. © 2008 Elsevier Masson SAS. All rights reserved. MOTS CLÉS Résumé Syndrome coronarien Objectif. — Le pronostic des syndromes coronariens aigus du sujet âgé est sombre et l’influence aigu ; des critères gériatriques demeure inconnue. L’objectif de ce travail est d’identifier les facteurs Sujets âgés ; prédictifs d’évolution défavorable à six mois d’une population de sujets âgés pris en charge Gériatrie ; pour un syndrome coronarien aigu. Mortalité ; Matériel et méthode. — Chez 132 patients de plus de 80 ans et 127 patients de moins de 80 ans Événements admis aux soins intensifs de cardiologie pour un syndrome coronarien aigu entre mai 2006 et cardiaques et janvier 2007, l’évolution, la mortalité et les évènements cardiovasculaires ont été comparés cérébrovasculaires en phase hospitalière et au sixième mois. majeurs Résultats. — Les sujets de plus de 80 ans sont moins souvent coronarographiés (85,6 % versus 97,7 %, p < 0,001) mais sont autant revascularisés (75,6 % versus 78,9 %, p = 0,58). L’évolution intrahospitalière est plus souvent compliquée (68,8 % versus 38,1 %, p < 0,0001) avec une mor- talité élevée (18,2 % versus 3,2 %, p = 0,0001). Après 80 ans, la mortalité toute cause au sixième mois est supérieure (28 % versus 10,6 %, p < 0,001). Les variables indépendamment associées à la mortalité toute cause à six mois chez les plus de 80 ans sont les suivants : une tension artérielle systolique inférieure à 100 mmHg, une fréquence cardiaque supérieure à 100 battements par minute à l’admission, l’existence d’un antécédent cardiovasculaire, un syndrome coronarien aigu avec sus-décalage du segment ST dans le territoire antérieur et l’absence de douleur thoracique. Conclusion. — Les critères gériatriques étudiés ne semblent pas influencer le pronostic des sujets âgés hospitalisés pour un syndrome coronarien aigu qui est dominé par le poids des variables cardiaques. © 2008 Elsevier Masson SAS. All rights reserved. Introduction unit (at Rangueil University Hospital in Toulouse) for ACS with elevated troponin and/or modification of the ST seg- Cardiovascular disease remains the leading cause of death in ment were included in a single-centre, prospective registry. subjects over 75 years of age [1] and, according to the esti- The usual clinical and paraclinical parameters were inves- mates of the National Institute for Statistics and Economic tigated as well as the treatment modalities administered Studies (INSEE), one French person in three will be over 60 by and details of discharge treatment. The following geriatric 2050 (compared with one in five today) [2]. The proportion criteria were also investigated: independence (defined as of elderly subjects included in the randomised, controlled independence from third parties in daily life), accommoda- trials is well below their representation in clinical practice tion (living at home or in an institution), eligibility for the [3]. According to studies of patients with acute coronary syn- state independence allowance, and score on the simplified drome (ACS), elderly subjects are less well treated, both in Instrumental Activities of Daily Living Scale (IADL) [16]. The medical and interventional terms [4,5], despite the fact that data collected were compared with those from a control recommended treatment modalities [6,7] are recognised as population composed of all the patients under 80 years of being effective even in those advanced in age [8—15]. age admitted consecutively into a cardiology intensive care In this study, we attempted to pinpoint factors that might unit with ACS between May and July 2006. predict poor outcome at six months in subjects over 80 years Subjects in both groups were followed up six months later of age who had been admitted into a cardiology intensive by telephone, at which time the following details were col- care unit with ACS, the purpose being to define ways of iden- lected: recurrence of ACS; whether a new revascularisation tifying patients at high risk. In addition to routine cardiologic procedure had been performed; stroke; an episode of left criteria, we investigated the predictive power of a series of heart failure (defined by the need to instigate diuretics or geriatric parameters. step up their dosage); death (either due to cardiovascular problems or some other cause); and treatment details. Materials and methods Statistical analysis From May 2006 to January 2007, all subjects of 80 years In the statistical analysis, all quantitative variables are of age or more admitted into a cardiology intensive care presented as the mean ± standard deviation. Qualitative ACS in the elderly 451 variables are expressed as the absolute and relative dis- blood pressure and heart rate, we used the threshold val- tribution. With a view to identifying factors that are ues of the TIMI scale [17]. The significance threshold p was significantly associated with the occurrence of a major car- taken as 0.05 for all statistical tests. diovascular event, univariate analysis was carried out. The Kruskal—Wallis test was used for quantitative variables and, for qualitative variables, the chi2 test or, if numbers were Results insufficient, the Exact Fischer test. Every variable found to be significant in the bivariate analysis was included in a Population logistic regression multivariate analysis, in order to identify factors that are independently and significantly associated One hundred and twenty-seven patients under 80 and 132 with the occurrence of a major cardiovascular event. For over 80 were included. Their characteristics are detailed Table 1 Population characteristics. Under 80 n (%) Over 80 n (%) p Number 127 132 Age (years) Meana 57.8 (13.6) 84.0 (3.1) Medianb 57.5 (47.0; 70.5) 84.0 (81.5; 85.0) Females 36 (28.1%) 64 (48.8%) < 0.001 Cardiovascular risk factors HBP 59 (46.5%) 105(80.1%) < 0.0001 Abnormal lipid metabolism 61 (48.0%) 45 (34.9%) 0.03 Diabetes 29 (23.0%) 27 (20.9%) 0.69 Heredity 35 (27.6%) 16 (12.4%) < 0.01 Smoking (absence) 48 (37.8%) 87 (68.0%) < 0.0001 Active smoking 49 (38.6%) 5 (3.9%) < 0.0001 Cardiovascular history Ischaemic heart disease 35 (27.6%) 51 (38.9%) 0.05 Angioplasty ± stenting 20 (15.9%) 16 (12.3%) 0.41 Coronary artery bypass 5 (4.0%) 8 (6.1%) 0.43 AOLL 10 (7.9%) 18 (13.9%) 0.13 Heart failure 8 (6.4%) 16 (12.3%) 0.10 Left valve disease 2 (1.6%) 9 (6.9%) 0.04 Vascular surgery 1 (0.8%) 14 (10.8%) < 0.001 Stroke 6 (4.8%) 8 (6.3%) 0.61 PM 3 (2.3%) 8 (6.3%) 0.13 IC and/or stroke and/or AOLL 40 (31.3%) 69 (52.3%) < 0.001 Clinical background Dementia 1 (0.8%) 8 (6.2%) 0.04 Depression 4 (3.2%) 7 (5.4%) 0.38 COPD 5 (4.0%) 5 (3.9%) 0.99 Severe bleeding 1 (0.8%) 3 (2.3%) 0.62 Neoplasia 11 (8.7%) 13 (10.0%) 0.73 A fall in the preceding 3 months 1 (0.8%) 20 (16.3%) < 0.0001 Lifestyle Independence Allowance — 24 (22.2%) Independence — 57 (49.6%) Institutionalised — 12 (10.4%) IADL score 0 — 10 (9.0%) 1 — 14 (12.6%) 2 — 14 (12.6%) 3 — 37 (33.3%) 4 — 36 (32.4%) IADL: instrumental activities of daily living: simplified version.