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Abstracts & Commentary
It is well known that older individuals have a higher prevalence of coronary artery disease (CAD), multivessel CAD, as well as CAD morbidity and mortality. Two recent reports provide useful information regarding the management of the elderly with severe symptomatic CAD. An analysis of Medicare patients with unstable angina hospitalized in Connecticut between August and November 1995 demonstrates that patients older than age 65 with unstable angina are often not treated appropriately. This assessment of 5 standard guidelines in unstable angina therapy, defined by the Agency for Healthcare Policy and Research, indicates that physicians underuse proven therapies for unstable angina in older individuals. The parameters assessed included a rapid ECG within 20 minutes of admission; aspirin use on admission and discharge; use of intravenous heparin; and target anticoagulation levels. The highest performance rates were for aspirin, 80% on admission and discharge. However, heparin use was just 60%, and therapeutic anticoagulation at some time within 48 hours was achieved in only 43% of individuals. Only half of the patients had a prompt ECG. Compliance with the unstable angina treatment guidelines varied markedly by hospital, with many institutions below 50% compliance for 1 or more of the 5 variables; the level of performance in 1 area did not correlate with that in others. Women and older subjects (> 85 years of age) were particularly less likely to receive anticoagulation or aspirin. African-American patients also received lower rates of ECG on admission. Individuals with known CAD were more likely to undergo early ECG and receive appropriate anticoagulation, as were patients with ECG repolarization changes and diabetics. Shahi and associates conclude that the significant variation in delivery of care for diagnosis of unstable angina is of great concern in this high-risk population. They point out that their data are concordant with other reports, and that this age group has been particularly underrepresented in the literature. (Shahi CN, et al. Am Heart J. 2001;142:263-270).
The trial of invasive vs. medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME) study from Switzerland is an investigation of patients with severe and/or refractory chest pain aged 75 or older, who were randomized to intensive medical therapy vs. early angiography and revascularization. Most of these subjects would qualify as having unstable angina, although many were outpatients at the time of entry into the study. Approximately 300 subjects, with an average age of 80, were enrolled. At entry, three-quarters of patients had CCS angina class II, and were taking a mean of 2.5 antianginal drugs each. LV function was mildly impaired; ischemia was detected in about half of the patients. The medical group received an increase in the number, as well as dose, of antianginal drugs; anti-platelet and lipid lowering agents were advised. The invasive patients received early angiography, followed by PCI or CABG when appropriate and feasible. The primary end point was a panel of quality-of-life indices, as well as a composite of death, nonfatal MI, and readmission for increasing angina. The patients were followed for 6 months. There were no baseline differences in symptom status or quality of life between the 2 groups. The results indicated that both medically treated and revascularized individuals had an improvement in angina and quality of life, but greater with the invasive strategy. Major adverse cardiac events were substantially less in the invasive group at 6 months, 19% vs. 49% in the optimal medical group, P = < 0.0001. There was a trend toward a higher mortality, however, in the invasive patients. Most of the event differences between the 2 cohorts were for repeat hospital admission for ACS. Major events were 40/153 in the invasive patients and 96/148 in the optimal medical strategy group. The latter patients had an increase in intensity of medical therapy, but there was a marked reluctance of treating physicians to use lipid-lowering drugs in these individuals. Specific details regarding the medical treatment are not provided. One third of the optimal medical group ultimately received revascularization for uncontrollable symptoms during follow-up; one quarter of the invasive patients did not undergo revascularization. There were 68 PCI and 25 CABG in this cohort. It was concluded that although there was a slight mortality hazard, related to procedure-related myocardial infarction, the invasive patients overall did much better, and recommend that in appropriate 80-year-old individuals with suitable coronary anatomy, revascularization should be strongly considered. They stress the absence in the literature of randomized trials comparing CABG or PCI to medical therapy in this age group. Nevertheless, the previously reported ACME and RITA-II trials were concordant, demonstrating an improvement in quality-of-life-measures overall in the revascularization cohorts. An accompanying editorial by Aronow emphasizes the paucity of randomized clinical trials in older patients, whether it be unstable angina, acute myocardial infarction, or congestive heart failure. Aronow concludes, ". . . despite their high-risk profile, patients older than 75 should be offered invasive evaluation and coronary revascularization procedures as clinically indicated." (TIME Investigators. Lancet. 2001;358:951-957).
Comment by Jonathan Abrams, MD
The Connecticut database indicates that the elderly are underassessed and undertreated when hospitalized for unstable angina. Many of these individuals present with atypical features, and comorbidity is a major problem. The markers of appropriate therapy assessed in "ideal patients" are straightforward, and do not involve high-tech medicine: aspirin and heparin being the major end points. The database represents a therapeutic time period that is somewhat out of date with contemporary treatment of ACS; however, it is unlikely that the experience in the elderly has improved today to include widespread use of IIb/IIIa receptor blockers, low molecular heparin, and clopidogrel. Regarding the Swiss report, at the very least, this small trial strongly supports a policy of coronary angiography in subjects who are considered to be adequate candidates for revascularization, based on comorbidity and physiologic function. These details are not provided, although there was a considerable amount of coexisting medical conditions of importance. The improvement in quality of life, without an increased risk, is important, as patients who are 75-85 years of age are surely more interested in feeling better rather than living longer without a substantial burden of symptoms. Other recent ACS trials in younger subjects also confirm that early invasive therapy for hospitalized patients may be more beneficial than medical therapy; although this report does not strictly deal with only hospitalized individuals, the message is concordant—with a significant burden of symptoms and/or ischemia in elderly patients with increasing or unstable angina, careful selection of individuals for invasive evaluation is appropriate.