Outcomes Among Older Patients With STEMI vs. NSTE-ACS

Study Questions:

What are the differential risks of mortality and nonfatal cardiovascular and cerebrovascular outcomes by myocardial infarction (MI) classification?

Methods:

Older patients ≥65 years with acute MI and significant coronary artery disease (CAD) identified with coronary angiography from the ACTION Registry-GWTG (Get With the Guidelines) were linked to Medicare claims data from 2007 to 2010. The investigators examined the unadjusted cumulative incidence of each outcome studied from hospital discharge through 2 years with log-rank tests and then performed a piece-wise proportional hazards modeling with two time periods: discharge to 90 days and 90 days to 2 years.

Results:

Among the 46,199 patients linked with Medicare data, 17,287 (37.4%) presented with ST-segment elevation MI (STEMI). Through 2 years, the unadjusted cumulative incidence of all-cause mortality (16.0% vs. 19.8%; p < 0.001) and the composite outcome (21.9% vs. 27.9%; p < 0.001) was lower for STEMI patients. Within the first 90 days, unadjusted rates of mortality (5.5% vs. 5.3%) and the composite outcome (7.9% vs. 8.1%) were similar, but diverged from 90 days to 2 years (mortality, 11.1% vs. 15.4%; p < 0.001; composite outcome, 15.2% vs. 21.5%; p < 0.001). After multivariable adjustment, the adjusted risks of mortality and the composite outcome through 90 days were higher for STEMI patients, whereas risks of mortality and the composite outcome were attenuated from 90 days through 2 years.

Conclusions:

The authors concluded that among older acute MI patients with angiographically confirmed CAD discharged alive, STEMI patients (compared with NSTE-acute coronary syndrome) were found to have a lower postdischarge mortality and composite cardiovascular and cerebrovascular outcomes through 2 years after hospital discharge.

Perspective:

This study reports that in a contemporary population of older patients with acute MI with significant CAD during in-hospital angiography, STEMI patients had lower unadjusted rates of mortality and composite cardiovascular and cerebrovascular outcomes from hospital discharge through 2 years at all time points, and these differences were accentuated after 90 days. This study provides insight into the time-dependent occurrence of ischemic cardiovascular and cerebrovascular outcomes by MI classification among older acute MI patients, and may have important health care policy implications regarding bundled payments.

Clinical Topics: Acute Coronary Syndromes, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: ACTION Registry-GWTG, Acute Coronary Syndrome, Coronary Angiography, Coronary Artery Disease, Geriatrics, Medicare, Myocardial Infarction, Outcome Assessment (Health Care), Patient Discharge, Risk Assessment, Secondary Prevention


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