European Heart Journal Advance Access originally published online on June 7, 2006
European Heart Journal 2006 27(13):1558-1564; doi:10.1093/eurheartj/ehl067
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International variation in invasive care of the elderly with acute coronary syndromes
1 Outcomes Research and Assessment Group, Duke Clinical Research Institute, Duke University Medical Center, Box 3411, Durham, NC 27710, USA
2 Duke Clinical Research Institute, Durham, NC USA
3 Green Lane Hospital, Auckland, New Zealand
4 New York University School of Medicine, New York, NY, USA
5 University Hospital Basel, Basel, Switzerland
6 Cleveland Clinic Foundation, Cleveland, OH, USA
7 Universitaire Zeikenhuizen Leuven, Leuven, Belgium
8 University of Alberta, Edmonton, Alberta, Canada
Received 30 May 2005; revised 16 March 2006; accepted 9 May 2006; online publish-ahead-of-print 7 June 2006.
* Corresponding author. Tel: +1 919 668 8871; fax: +1 919 668 7057. E-mail address: karen.alexander{at}duke.edu
Aims To explore variations in invasive care of the elderly with acute coronary syndromes across international practice.
Methods and results Using combined populations from the SYMPHONY and 2nd SYMPHONY trials, we describe 30-day cardiac catheterization in elderly (
75 years; n=1794) vs. younger patients (<75 years; n=14 043) after multivariable adjustment and by region of enrolment. The use of cardiac catheterization and revascularization were not protocol-specified. Elderly patients (median age 78 years) were more often female and more frequently had hypertension, diabetes, prior myocardial infarction, and prior coronary bypass surgery. Overall, they underwent less cardiac catheterization than younger patients [53 vs. 63%; adjusted OR 0.53 (0.46, 0.60)]. The absolute rate of cardiac catheterization in the elderly varied from 77% (vs. 91% in younger patients) in the US cohort to 27% (vs. 41% in younger patients) in the non-US cohort. Revascularization of elderly who underwent cardiac catheterization was also higher in US than non-US cohorts (71.3 vs. 53.6%). There was a significant interaction between the patient age and the use of catheterization across US and non-US regions of enrolment, as well as differences in the predictors of catheterization in the elderly. Despite these findings, after adjustment, 90-day rates of death and death or myocardial infarction (MI) were not significantly different in elderly who underwent catheterization compared with those who did not.
Conclusion Although older age is universally predictive of lower use of cardiac catheterization, marked variation in catheterization of the elderly exists across international practice. Demonstrated differences in patterns of use suggest a lack of consensus regarding optimal use of an invasive strategy in the elderly.
Key Words: Acute coronary syndromes • Elderly • Cardiac catheterization • International comparisons
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