 |
 |
|
Home |
Current Issue |
Past Issues |
In the Clinic |
ACP Journal Club |
CME |
Collections |
Audio/Video |
Mobile |
Subscribe |
Tools |
Help |
ACP Online
|
Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.
SUMMARIES FOR PATIENTS
Invasive versus Conventional Management of Elderly Patients with Acute Coronary Artery Disease: Which Is Better?
3 August 2004 | Volume 141 Issue 3 | Page I-56
Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians.
The summary below is from the full report titled "The Effect of Management Strategy on Clinical Outcome for Elderly Patients with Non–ST-Segment Elevation Acute Coronary Syndromes." It is in the 3 August 2004 issue of Annals of Internal Medicine (volume 141, pages 186-195). The authors are R.G. Bach, C.P. Cannon, W.S. Weintraub, P.M. DiBattiste, L.A. Demopoulos, H.V. Anderson, P.T. DeLucca, E.M. Mahoney, S.A. Murphy, and E. Braunwald.
What is the problem and what is known about it so far?
Signs of acute coronary artery disease lead to nearly 1.5 million hospital admissions each year in the United States. These patients have either angina (chest pain) or myocardial infarction (MI), which is commonly called a heart attack. At the hospital, they routinely receive medical treatments, including blood thinners to prevent blood clots. Doctors may choose conservative management, which means simply watching the patient closely and performing a stress test, or an early invasive approach, which calls for angiography shortly after admission. This x-ray examination shows whether there are significant blockages in the coronary arteries. If necessary, coronary intervention or surgery can be done to restore adequate blood flow to the heart wall. A majority of patients are 65 years of age or older. They tend to have invasive treatment less often than younger patients. Whether invasive measures improve the outlook for elderly patients remains uncertain.
Why did the researchers do this particular study?
To learn whether clinical outcomes in patients with acute coronary artery disease depend on age and management strategy.
Who was studied?
2220 patients at 169 hospitals in 9 countries who had acute symptoms of coronary artery disease. They included 962 patients (43%) 65 years of age and older.
How was the study done?
The researchers followed patients from the time of hospital admission. Assignment to conservative management or early invasive treatment was on a random basis. Patients managed invasively had coronary angiography 4 to 48 hours after admission. Follow-up after 30 days and 6 months compared rates of death and nonfatal MI according to age and type of treatment. The researchers also kept track of strokes and bleeding.
What did the researchers find?
After 6 months of follow-up, patients 65 years of age and older were much more likely than younger patients to die or have an MI. Although they made up less than 45% of the study group, they accounted for 71% of all deaths and 53% of MIs. Within this age group, patients treated invasively had a 39% reduction in the combined rate of death and nonfatal MI after 6 months. The difference between the invasive and conventional treatment groups was even greater in patients 75 years of age and older. In this age group, invasive treatment correlated with a 56% reduction in death or MI at 6 months. Invasive treatment also provided better outcomes in patients younger than 65 years of age, but not to a significant degree. In patients 75 years of age and older, invasive treatment more than doubled the risk for major bleeding.
What were the limitations of the study?
The study excluded patients with other serious illnesses. For this reason, those studied may have been healthier than many patients with acute coronary artery disease.
What are the implications of the study?
Routine invasive management of elderly patients with acute symptoms of coronary artery disease can prevent many nonfatal MIs and deaths. Patients older than 75 years of age, however, are at increased risk for major bleeding.
Related articles in Annals:
This article has been cited by other articles:
|
|
 |
|
  P. V. Ennezat, N. Lamblin, F. Mouquet, O. Tricot, P. Quandalle, V. Aumegeat, O. Equine, O. Nugue, B. Segrestin, P. de Groote, et al. The effect of ageing on cardiac remodelling and hospitalization for heart failure after an inaugural anterior myocardial infarction Eur. Heart J., June 20, 2008; (2008) ehn267v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Devlin, J. M. Gore, J. Elliott, N. Wijesinghe, K. A. Eagle, A. Avezum, W. Huang, D. Brieger, and for the GRACE Investigators Management and 6-month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: The Global Registry of Acute Coronary Events Eur. Heart J., May 2, 2008; 29(10): 1275 - 1282. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Bauer, O. Koeth, C. Junger, T. Heer, H. Wienbergen, A. Gitt, R. Zahn, J. Senges, U. Zeymer, and for the Acute Coronary Syndromes Registry (ACOS) I Effect of an invasive strategy on in-hospital outcome in elderly patients with non-ST-elevation myocardial infarction Eur. Heart J., December 1, 2007; 28(23): 2873 - 2878. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): e1 - e157. [Full Text] [PDF]
|
|
|
|
|
|
J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): 652 - 726. [Full Text] [PDF]
|
|
|
|
|
|
E. Nikolsky, R. Mehran, G. Dangas, M. Fahy, Y. Na, S. J. Pocock, A. M. Lincoff, and G. W. Stone Development and validation of a prognostic risk score for major bleeding in patients undergoing percutaneous coronary intervention via the femoral approach Eur. Heart J., August 2, 2007; 28(16): 1936 - 1945. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Authors/Task Force Members, J.-P. Bassand, C. W. Hamm, D. Ardissino, E. Boersma, A. Budaj, F. Fernandez-Aviles, K. A.A. Fox, D. Hasdai, E. M. Ohman, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology Eur. Heart J., July 1, 2007; 28(13): 1598 - 1660. [Full Text] [PDF]
|
|
|
|
 |
|
 K. P. Alexander, L. K. Newby, C. P. Cannon, P. W. Armstrong, W. B. Gibler, M. W. Rich, F. Van de Werf, H. D. White, W. D. Weaver, M. D. Naylor, et al. Acute Coronary Care in the Elderly, Part I: Non-ST-Segment-Elevation Acute Coronary Syndromes: A Scientific Statement for Healthcare Professionals From the American Heart Association Council on Clinical Cardiology: In Collaboration With the Society of Geriatric Cardiology Circulation, May 15, 2007; 115(19): 2549 - 2569. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. S. Hollenbeak, J. P. Fitzgibbons, M. Rossi, D. L. Morris, and P. Stillman The Impact of Percutaneous Coronary Interventions on Outcomes for Acute Myocardial Infarction in Pennsylvania American Journal of Medical Quality, March 1, 2007; 22(2): 85 - 94. [Abstract] [PDF]
|
|
|
|
 |
|
 N. Bhala, M. Hamon, J. W. Riddell, G. Karthikeyan, V. Pasceri, J. Schuler, J. Altenberger, M. Heigert, G. Montalescot, H. D. White, et al. Enoxaparin in elective percutaneous coronary intervention. N. Engl. J. Med., December 28, 2006; 355(26): 2788 - 2789. [Full Text] [PDF]
|
|
|
|
 |
|
 J. Collinson, A. Bakhai, A. Taneja, D. Wang, and M.D. Flather Admission ECG predicts long-term outcome in acute coronary syndromes without ST elevation QJM, September 1, 2006; 99(9): 601 - 607. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Kaehler, T. Meinertz, and C. W Hamm Coronary interventions in the elderly. Heart, August 1, 2006; 92(8): 1167 - 1171. [Full Text] [PDF]
|
|
|
|
|
|
K. P. Alexander, L. K. Newby, M. V. Bhapkar, H. D. White, J. S. Hochman, M. E. Pfisterer, D. J. Moliterno, E. D. Peterson, F. Van de Werf, P. W. Armstrong, et al. International variation in invasive care of the elderly with acute coronary syndromes Eur. Heart J., July 1, 2006; 27(13): 1558 - 1564. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. S Birkhead, C. Weston, D. Lowe, and National Audit of Myocardial Infarction Project (M Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004-5: observational study BMJ, June 3, 2006; 332(7553): 1306 - 1311. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Khatri and S. E. Kasner Ischemic strokes after cardiac catheterization: opportune thrombolysis candidates? Arch Neurol, June 1, 2006; 63(6): 817 - 821. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Rosengren, L. Wallentin, M. Simoons, A. K Gitt, S. Behar, A. Battler, and D. Hasdai Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey Eur. Heart J., April 1, 2006; 27(7): 789 - 795. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. D. Chiara, C. Fresco, S. Savonitto, C. Greco, D. Lucci, L. Gonzini, A. Mafrici, F. Ottani, L. Bolognese, S. De Servi, et al. Epidemiology of non-ST elevation acute coronary syndromes in the Italian cardiology network: the BLITZ-2 study Eur. Heart J., February 2, 2006; 27(4): 393 - 405. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. P. Alexander, M. T. Roe, A. Y. Chen, B. L. Lytle, C. V. Pollack Jr, J. M. Foody, W. E. Boden, S. C. Smith Jr, W. B. Gibler, E. M. Ohman, et al. Evolution in Cardiovascular Care for Elderly Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: Results From the CRUSADE National Quality Improvement Initiative J. Am. Coll. Cardiol., October 18, 2005; 46(8): 1479 - 1487. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. V. Anderson and R. G. Bach The Elderly Are Not So Old Anymore J. Am. Coll. Cardiol., October 18, 2005; 46(8): 1488 - 1489. [Full Text] [PDF]
|
|
|
|
 |
|
 F. Liistro, K. Ducci, G. Falsini, and L. Bolognese Early invasive strategy in elderly patients with non-ST-elevation acute coronary syndromes Eur. Heart J. Suppl., October 1, 2005; 7(suppl_K): K23 - K25. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F Liistro, P Angioli, G Falsini, K Ducci, S Baldassarre, A Burali, and L Bolognese Early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome: comparison with younger patients regarding 30 day and long term outcome Heart, October 1, 2005; 91(10): 1284 - 1288. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. P. Giugliano and E. Braunwald The Year in Non--ST-Segment Elevation Acute Coronary Syndromes J. Am. Coll. Cardiol., September 6, 2005; 46(5): 906 - 919. [Full Text] [PDF]
|
|
|
|
|
|
L. Green Benefits of early invasive treatment for acute coronary syndromes: lost in translation? BMJ, May 14, 2005; 330(7500): E351 - E352. [Full Text] [PDF]
|
|
|
|
|
|
Authors/Task Force Members, S. Silber, P. Albertsson, F. F. Aviles, P. G. Camici, A. Colombo, C. Hamm, E. Jorgensen, J. Marco, J.-E. Nordrehaug, et al. Guidelines for Percutaneous Coronary Interventions: The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology Eur. Heart J., April 2, 2005; 26(8): 804 - 847. [Full Text] [PDF]
|
|
|
|
 |
|
 T. A. Stukel, F. L. Lucas, and D. E. Wennberg Long-term Outcomes of Regional Variations in Intensity of Invasive vs Medical Management of Medicare Patients With Acute Myocardial Infarction JAMA, March 16, 2005; 293(11): 1329 - 1337. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 ADDITIONAL ARTICLES ABSTRACTED IN ACP JOURNAL CLUB Evid. Based Med., February 1, 2005; 10(1): 3 - 3. [Full Text] [PDF]
|
|
|
|
|
|
T. J. Gluckman, M. Sachdev, S. P. Schulman, and R. S. Blumenthal A Simplified Approach to the Management of Non-ST-Segment Elevation Acute Coronary Syndromes JAMA, January 19, 2005; 293(3): 349 - 357. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. A. Masoodi Age and Routine Invasive Management of Acute Coronary Syndromes Ann Intern Med, December 21, 2004; 141(12): 967 - 967. [Full Text] [PDF]
|
|
|
|
|
|
D. L. Bhatt, M. T. Roe, E. D. Peterson, Y. Li, A. Y. Chen, R. A. Harrington, A. B. Greenbaum, P. B. Berger, C. P. Cannon, D. J. Cohen, et al. Utilization of Early Invasive Management Strategies for High-Risk Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: Results From the CRUSADE Quality Improvement Initiative JAMA, November 3, 2004; 292(17): 2096 - 2104. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Early Invasive Strategy for Elders with Non-ST-Segment-Elevation ACS Journal Watch Cardiology, September 10, 2004; 2004(910): 1 - 1. [Full Text]
|
|
|
|
 |
|
 Get Those Old Folks to the Cath Lab Journal Watch Emergency Medicine, August 25, 2004; 2004(825): 1 - 1. [Full Text]
|
|
|
|
 |
|
 Does Early Invasive Management Benefit Elders with Non-ST-Segment-Elevation ACS? Journal Watch (General), August 24, 2004; 2004(824): 1 - 1. [Full Text]
|
|
Read all Rapid Responses
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Article
