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Elderly patients with acute myocardial infarction (MI) are more likely to receive percutaneous coronary intervention (PCI) in the United States than Sweden. A study published online June 25, 2013, ahead of print in the European Heart Journal also found that long-term survival was better for those who received intervention.
Using a population-based sample of elderly hospitalized AMI patients, researchers led by Russell V. Luepker, MD, of the University of Minnesota (Minneapolis, MN), compared treatment approaches and outcomes for 839 patients treated in Minneapolis-St. Paul and 564 comparable patients treated in Göteborg, Sweden, from July 2001 through June 2002.
Invasive Procedures More Common in USUse of diagnostic coronary angiography was more frequent among both men and women treated in Minneapolis vs. those in Sweden. Furthermore, use of PCI following angiography was more than 4 times as frequent among men and women in Minneapolis-St. Paul. At 7.5 years, survival was higher for US compared with Swedish patients for both men and women (tables 1 and 2).
Table 1. Procedure Use, Long-term Survival (Men)
(n = 387)
(n = 275)
Table 2. Procedure Use, Long-term Survival (Women)
(n = 452)
(n = 289)
While guideline-based medication use was high in both locations, the use of thrombolysis was somewhat higher in Sweden compared with Minneapolis for both men (6.9% vs. 3.6%; P = 0.07) and women (8.0% vs. 4.6%; P = 0.06). However, the prescription of lipid-lowering agents at discharge was much higher in Minneapolis-St. Paul compared with Göteborg, for both men (51.8% vs. 35.9%; P = 0.001) and women (44.8% vs. 23.7%; P < 0.0001).
After adjustment for baseline characteristics, guideline-based therapies, and type of MI (STEMI vs. non-STEMI), 7.5-year mortality remained lower for US patients compared with their Swedish counterparts for both men (adjusted HR 0.66; 95% CI 0.50-0.88) and women (adjusted HR 0.49; 95% CI 0.36-0.67). Further adjustment for in-hospital use and discharge prescription of antiplatelets yielded results consistent with the primary analysis.
However, in multivariable analysis restricted to patients who underwent PCI, 7.5-year mortality was no different between US and Swedish men (HR 0.70; 95% CI 0.37-1.34), or women (HR 0.67; 95% CI 0.32-1.41).Cultural Differences in Intervention
In a telephone interview with TCTMD, Jeffrey W. Moses, MD, of Columbia University Medical Center/Weill Cornell Medical Center (New York, NY), said by focusing on patients over age 80 from 2 different healthcare systems, the study provides a unique look at a population that is already widely recognized as being undertreated.
“It’s interesting because the centralized healthcare system is often held up as the model we should look to, and here we show that there is a differential in that we are spending money but saving lives,” he said. “Frankly, I think it also demonstrates that in certain cultures there is a tendency to deploy services less frequently in the elderly. Here it’s clear that [that attitude] probably costs lives.
Dr. Moses said he believes the explanation for the difference in PCI use comes down to a higher rate of discretionary use by US providers. But he also cautioned that the study data are a decade old, so it is possible that practices have changed somewhat since that time.
“Still, I do think this tells us that we need to pay attention and [not dismiss] the sicker patients and the elderly when it comes to interventions that save lives,” Dr. Moses concluded.Study Details
Patients in Minneapolis-St. Paul were treated at 1 of 21 acute care hospitals, while those in Göteborg were treated at 2 acute care hospitals, each serving half of the city.
Age was similar between patients treated in both countries for men (Minneapolis-St. Paul 83 ± 7 years, Göteborg 82 ± 5 years) and women (Minneapolis-St. Paul 84 ± 6 years, Göteborg 84 ± 6 years). Minneapolis-St. Paul patients had more previous cardiovascular comorbidities and procedures including PCI and CABG.
Smith LG, Herlitz J, Karlsson T, et al. International comparison of treatment and long-term outcomes for acute myocardial infarction in the elderly: Minneapolis/St. Paul, MN, USA and Göteborg, Sweden. Eur Heart J. 2013;Epub ahead of print.