Better Care Seen for Elderly ACS Patients in England, Wales, But Biases Remain

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Since 2003, in-hospital mortality among patients with acute coronary syndromes (ACS) has decreased significantly across all age groups in England and Wales, according to a study published online October 18, 2011, ahead of print in the European Heart Journal. The improvement has specifically benefitted the elderly, despite ongoing age-related biases in treatment, the authors say.

Using data from the Myocardial Ischaemia National Audit Project (MINAP), Chris P. Gale, BSc, MBBS, MRCP, PhD, of the University of Leeds (Leeds, United Kingdom), and colleagues analyzed 616,011 ACS events at 255 hospitals across England and Wales from 2003 to 2010. Patients were split into 5 age groups, with those under 55 years (n = 102,415) at the low end and those 85 years and older (n = 72,721) at the high end.

The proportion of men ranged from about 80% of the cohort aged younger than 55 years to about 42% of patients 85 years and older.

Improvements Across the Board

STEMI was diagnosed in 33.8% of patients, and about 52.8% of patients were diagnosed with non-ST elevation ACS, further broken down into NSTEMI and unstable angina.

For both STEMI and NSTEMI, the risk of in-hospital mortality increased with age, with the highest risk of death occurring in men aged 85 or older with STEMI (OR 20.31; 95% CI 17.97-22.95). Older patients had longer lengths of stay in hospital and higher in-hospital mortality rates (P < 0.001) compared with their younger counterparts.

However, over the study period, reductions in in-hospital mortality were seen across all age groups and for both STEMI and NSTEMI, though the difference was not statistically significant for the youngest patients (table 1).

Table 1. In-Hospital Mortality by Year of Admission

Diagnosis and Age Group



Relative Risk
(95% CI)

< age 55
≥ age 85



0.72 (0.39-1.25)
0.54 (0.38-0.75)

< age 55
≥ age 85



0.89 (0.48-1.34)
0.56 (0.42-0.73)


However, despite the improved outcomes, older patients were less likely to undergo angiography or echocardiography (both P < 0.001). In addition, STEMI patients 85 or older were 73% less likely to be reperfused than younger STEMI patients (RR 0.27; 95% CI: 0.25-0.28). Elderly STEMI or NSTEMI patients were also considerably less likely to receive aspirin, clopidogrel, beta-blockers, ACE inhibitors, or statins than similar ACS patients younger than 55.

Still, between 2003 and 2010, rates of primary PCI for STEMI patients increased from 1.6% to 60.9% for younger patients and from 0.2% to 48.5% for older patients (both P < 0.001). There were also significant increases in the use of evidence-based pharmacological therapy.

Despite Changes, Elderly Still Undertreated

“To date, many studies have described the differential presentation, management, and outcome of elderly vs. young ACS patients. This research corroborates these findings; revealing that the profile of the elderly hospitalized with an ACS has not changed greatly. What has changed is the reduction in in-hospital mortality,” the authors write.

They note that standards of care have improved over time, for example enabling elderly patients to undergo angiography and PCI, when advanced age alone is not a contraindication.

Despite these improvements, discrepancies in care remain, and the authors suggest multiple possible causes, including lack of appropriate specialist care and inappropriate placement within the hospital.

But in a telephone interview with TCTMD, Harlan Krumholz, MD, of Yale University School of Medicine (New Haven, CT), found the focus on age-related differences in care misplaced. “I am always a little perplexed about studies that try and make this contrast between the young and the old,” he said. “It’s no real surprise that older patients have higher mortality rates than younger patients. I think the most interesting part of the article is the decrease in mortality over time and the fact that it seems like everyone is experiencing this benefit.”

Accentuate the Positive

While the researchers only studied patients in England and Wales, Dr. Krumholz said that the changes in in-hospital mortality rates “are just extraordinary in a relatively short period of time.” To further solidify the study’s findings, he said, more detail on changes in practice is needed.

The authors broadly attribute the decrease in mortality rates to clinical initiatives specific to the geographic area they studied. “Improvements in mortality are associated with the application of evidence-based medicine, and it is likely that the implementation of strategic networks of care (such as the national primary PCI service in England and Wales) has contributed to the greater application of ACS treatments and hence better outcomes,” they write.

Dr. Krumholz said that because the investigators provided little detail regarding the changes in clinical care over time, it is difficult to evaluate the true quality of care. Future research should focus on this topic, he added.

“I’m just not sure how they handled contraindications and patient preference and other factors like important comorbidities,” Dr. Krumholz said. “I would like to know how the patterns showed change over time in the various groups. How did the patients at the end of the [study] period compare to the patients at the beginning of the [study] period in all the treatment strategies?”

Study Details

While older patients were less likely to be current smokers, they more often had hypertension, prior AMI, angina, chronic heart failure, and chronic renal failure compared to the younger cohorts. Older patients were also less likely to call emergency services, go to the hospital on their own, and be admitted to the Cardiac Care Unit under the supervision of a consultant cardiologist. They also were more likely to have an ACS in the hospital.


Gale CP, Cattle BA, Woolston A, et al. Resolving inequalities in care? Reduced mortality in the elderly after acute coronary syndromes. The Myocardial Ischaemia National Audit Project 2003-2010. Eur Heart J. 2011:Epub ahead of print.



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  • Drs. Gale and Krumholz report no relevant conflicts of interest.