Real-world treatment of patients with acute coronary syndromes

A review of more than 56,000 cases of acute coronary syndromes reveals that older patients are less likely to receive treatment recommended by guidelines, even though they benefit as much or more than younger patients when the recommended treatment is provided, according to a new study in the Oct. 18, 2005, issue of the Journal of the American College of Cardiology.

"Our study is unique in that it describes early use of therapies, defined as those within the first 24 hours, and is targeted at guideline-recommended care. In fact, although improvements have been realized in adherence to discharge therapies, we found early use of therapies was where some of the largest differences between young and old patients remained. In addition, we demonstrated an inverse relationship between the number of evidence-based therapies applied and in-hospital death in young and old subgroups alike. Although any observational analysis may suffer from residual confounding, we demonstrate that older patients, as a group, benefit equally from guideline-recommended care," said Karen P. Alexander, M.D., from the Duke University Medical Center in Durham, North Carolina.

This analysis used data collected as part of an effort to document the real-world treatment of patients with acute coronary syndromes, including unstable angina and heart attacks. Information on 56,963 patients treated at 443 hospitals across the U.S. was collected for the CRUSADE National Quality Improvement Initiative from January 2001 to June 2003. CRUSADE is an initiative that is designed to increase the practice of evidence-based medicine for patients diagnosed with non-ST segment elevation acute coronary syndromes (NSTE ACS).

The patients were split into four age groups (younger than 65, 65 to 74, 75 to 84, and 85 or older). Rates of rapid use of drugs that reduce or prevent blood clots decreased with age. Elderly patients were also less likely to undergo diagnostic catheterization procedures, angioplasty or coronary artery bypass surgery. Most medications prescribed at hospital discharge were similar across all age groups; however, elderly patients were less likely to receive clopidogrel (an anti-platelet drug meant to reduce the risk of blood clots) or cholesterol-lowering drugs. The differences were apparent even after adjusting the treatment data to take into account known contraindications to treatment and other diseases that might have influenced treatment decisions.

The researchers also noted that although death rates and complications rose with advancing age, elderly patients who received more recommended therapies were less likely to die than those who did not.

Dr. Alexander said that progress is being made toward providing recommended treatment to patients of all ages, but this study shows there is more work to be done.

"Awareness of gaps is the first step in narrowing them. Further work on lipid lowering in the very elderly, and early identification of acute coronary syndrome symptoms in the aged, are areas which will benefit from continued work," she said.

Dr. Alexander noted that hospitals volunteer to participate in CRUSADE and they receive web-based educational sessions about the treatment of acute coronary syndromes. The study focused on the specific treatments recommended by ACC/AHA guidelines, so it did not collect data on aspects of care or details of other illnesses patients may have had. However, she said that enrollment was specific to patients with an acute coronary syndrome, and that the large number of hospitals and patients should provide a fairly representative view of current clinical practice.

H. Vernon Anderson, M.D., F.A.C.C., from the University of Texas Health Science Center at Houston, who wrote an editorial in the journal with Richard G. Bach, M.D., F.A.C.C. from the Washington University Medical Center in St. Louis, Missouri, said this report is part of an extremely important effort to understand how clinicians are actually treating heart patients.

"There's a reluctance to be 'aggressive' in older people, that somehow they are more fragile, that they have greater problems with medications, that you have to be somehow more gentle about doing things. And I think here are data that suggest that just isn't true; that in fact, while the elderly do have increased risks, on the other hand the potential benefits of treatment are greater, too. That's a strong argument that we should be treating the elderly very much more like we are treating the non-elderly. That in fact they are going to get a net benefit out of the treatment," Dr. Anderson said.

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