European Heart Journal Advance Access published online on June 7, 2006
European Heart Journal, doi:10.1093/eurheartj/ehl067
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1 Outcomes Research and Assessment Group, Duke Clinical Research Institute, Duke University Medical Center, Box 3411, Durham, NC 27710, USA
* To whom correspondence should be addressed. 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 ( 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.
Received May 30, 2005
Revised March 16, 2006
Accepted May 9, 2006
Clinical research
International variation in invasive care of the elderly with acute coronary syndromes
Karen P. Alexander 1 *,
Laura Kristin Newby 2,
Manju V. Bhapkar 2,
Harvey D. White 3,
Judith S. Hochman 4,
Matthias E. Pfisterer 5,
David J. Moliterno 6,
Eric D. Peterson 1,
Frans Van de Werf 7,
Paul W. Armstrong 8,
Robert M. Califf 2,
and
for the SYMPHONY and second SYMPHONY Investigators
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
Karen P. Alexander, E-mail: karen.alexander{at}duke.edu
Abstract 
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.
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