|Year : 2018 | Volume
| Issue : 3 | Page : 93-99
Comparative analysis of acute coronary syndrome in the elderly and the young: A hospital-based observational study
Abhikant Chugh MBBS 1, Sohaib Ahmad MD, DTM and H 1, Anurag Rawat MD, DNB 2, Minakshi Dhar MD 3
1 Department of Medicine, HIMS, SRH University, Dehradun, India
2 Department of Cardiology, HIMS, SRH University, Dehradun, India
3 Department of Medicine, AIIMS, Rishikesh, Uttarakhand, India
|Date of Web Publication||10-Jul-2018|
Dr. Sohaib Ahmad
Department of General Medicine, HIMS, SRHU, Jolly Grant, Dehradun, Uttarakhand
Source of Support: None, Conflict of Interest: None
Background: The high prevalence of acute coronary syndromes (ACS) and the imminent transition of a proportion of the population into the geriatric age group are issues vital to the health-care delivery system. We wished to compare the risk factors, clinical presentation, echocardiographic and angiographic findings, complications, and in-hospital outcomes of ACS in the elderly and the younger population and identify the predictors of mortality in the elderly. Materials and Methods: This observational cross-sectional study was performed on patients hospitalized with ACS over a 12-month period. Demographic, clinical, and laboratory data of all included patients were analyzed after categorizing them as Groups I (>60 years; n = 188) and II (<60 years; n = 123). Results: Congestive heart failure (n = 64; 20.6%), shock (n = 19; 6.1%), and arrhythmias (n = 9; 2.9%) were observed at presentation in the 311 patients studied. Intervention was not undertaken in 18/311 (5.8%) either due to poor general condition or refusal by the patients' attendants. The risk factors significantly associated (P < 0.05) in Group II included male gender, tobacco and alcohol use, central obesity, dyslipidemia, and a positive family history of coronary artery disease (CAD). Group II had significantly higher (P < 0.05) Killip class, heart failure, and shock at presentation and mortality. Conclusion: The risk factors of CAD differ in the elderly; also they are predisposed to adverse outcome as compared to the younger people. Mortality among the elderly is significantly higher in those with arrhythmias, shock, low diastolic blood pressure, and/or congestive heart failure with advanced Killip class.
Keywords: Acute coronary syndrome, elderly, mortality, risk factors
|How to cite this article:|
Chugh A, Ahmad S, Rawat A, Dhar M. Comparative analysis of acute coronary syndrome in the elderly and the young: A hospital-based observational study. J Clin Prev Cardiol 2018;7:93-9
|How to cite this URL:|
Chugh A, Ahmad S, Rawat A, Dhar M. Comparative analysis of acute coronary syndrome in the elderly and the young: A hospital-based observational study. J Clin Prev Cardiol [serial online] 2018 [cited 2022 Jan 18];7:93-9. Available from: https://www.jcpconline.org/text.asp?2018/7/3/93/236331
| Introduction|| |
Coronary artery disease (CAD) is a major cause of mortality and is a global health problem reaching epidemic proportions in both developed as well as developing countries. Although during the past four decades, there has been a slow but steady decline in age-adjusted mortality rates following acute myocardial infarction (MI), the incidence of acute coronary syndrome (ACS) per se, has not declined. The South Asians have the highest rates of CAD globally, and the disease is expected to be the most common cause of death in India by the year 2020.
The life expectancy of the world population is increasing. Aging populations represent a greater concern for healthcare, with limited resources and lack of preparedness for dealing with the special needs of this age group. The disparities and challenges in caring for ACS in older adults are well recognized. The problem is gloomier for developing countries like India, where the patients mostly pay out-of-the-pocket for accessing the inequitably distributed health-care facilities, lack of state-funded health-care access, and negligible social support for the economically nonproductive elderly. Implementation of evidence-based therapies has significantly decreased mortality and morbidities of ACS. However, these advancements in ACS management have not improved outcomes for older adults. The elderly represent an increasingly important and challenging subset of the population of patients with ischemic heart disease. They are more likely to have comorbidities, atypical presentations, and unfavorable outcomes than their younger counterparts., Vulnerable older patients continue to be at high risk of poor outcomes, are less likely to receive evidence-based care, and have high mortality rates regardless of treatments given.
We planned to study the clinical presentation of ACSs in the elderly and the younger patients, to assess the risk factors in these groups, complications, and in-hospital mortality. We also intended to study the differences in the subgroups of the elderly with ACS on the basis of their outcomes.
| Materials and Methods|| |
Ours was an observational cross-sectional study on all consecutive patients hospitalized in a tertiary referral center of North Indian hilly state of Uttarakhand over a period of 12 months (September 2016–August 2017) with the final diagnosis of ACS (based on ACC-AHA guidelines). Patients were recruited after obtaining written informed consent and ethical clearance from the Institutional Ethics Committee. They were categorized into two groups on the basis of age – those in Group I comprised the elderly aged ≥60 years whereas Group II were aged <60 years.
Data pertaining to the demography, comorbidities, clinical features, electro- and echo-cardiographic findings, angiography results, and laboratory parameters on admission were compiled, and all the cases were followed till discharge or death.
Cases were labeled as diabetics (WHO-ADA guidelines), hypertensives (JNC-VII guidelines), and with dyslipidemia (NCEP-ATP-III guidelines). Current smoker was defined as a person smoking cigarettes within 1 month of admission. A positive family history for CAD was defined as evidence of CAD before age 55 years in father or other male first-degree relative or before age 65 years in mother or other female first-degree relative. while obesity was defined as body mass index (BMI) >25 kg/m 2.
Statistical analysis was done using statistical software SPSS 22 version (Armonk, NY: IBM Corp). Continuous variables were expressed as mean ± standard deviation while the differences in their means were analyzed with Mann–Whitney U-test. Categorical variables were expressed as percentages and association between the groups was assessed by Pearson's Chi-square test. The statistical significance was considered if P < 0.05.
| Results|| |
A total of 311 patients (mean age 59.5 years, range 30–99) were included in the study. Of these, 57.5% and 34.4% were between 60 and 79 years and 41–59 years, respectively. Males constituted 77.8% of all cases. Classical anginal pain was present in 20.9% whereas retrosternal pain was evident in 93.2% patients. Sweating (19%), breathlessness (17%), and palpitations (15.8%) were the other major presenting complaints. The mean heart rate was 81.9 beats/min, systolic blood pressure (BP) 126.0 mm Hg, and diastolic BP was 79.3 mm Hg at presentation. Diabetes (34.1%), hypertension (29.8%), tobacco use (62.1%), alcohol (28.3%), and a family history of CAD (18.3%) were the main risk factors. The mean BMI of our study participants was 25.0%, and dyslipidemia was detected at admission in 42.8% cases. low-density lipoprotein (LDL) (139.1 ± 41.0 mg/dl), high-density lipoprotein (37.7 ± 8.8 mg/dl), triglycerides (177.0 ± 42.4 mg/dl), and very LDL (32.6 ± 18.7 mg/dl) were the lipid subsets of the study population. Cardiac troponin was positive in 27% at presentation while serial estimation was positive in most of the cases (96.7%).
Of the 311 cases studied, 188 were categorized as Groups I and 123 as Group II. A comparison of the demographic, clinical, laboratory, echocardiographic, and angiographic characteristics of the two groups is shown in [Table 1]. Of the 311 patients, congestive heart failure (n = 64; 20.6%), shock (n = 19; 6.1%), and arrhythmias (n = 9; 2.9%) were observed at presentation. Angiography and/or intervention could not be undertaken in 18/311 (5.8%) either due to poor general condition or refusal by the patients' attendants.
|Table 1: Comparison of risk factors, clinical and laboratory parameters, complications, and outcome of patients with acute coronary syndromes|
Click here to view
Overall, 15 patients (4.8%) succumbed to the acute coronary event and associated complications; 13/15 mortalities were from Group II. A comparison of the various demographic, clinical, laboratory, echocardiographic, and angiographic characteristics of those who survived versus those who succumbed is summarized in [Table 2].
|Table 2: Comparison of risk factors, clinical and laboratory parameters, complications, and outcome of elderly patients with acute coronary syndromes in relation to their outcome|
Click here to view
| Discussion|| |
The elderly presenting with an ACS have a risk factor profile different from the younger participants and a greater predisposition to adverse outcome as compared to them. Mortality among the elderly is significantly higher in those with arrhythmias, shock, low diastolic BP, and/or congestive heart failure with advanced Killip class precluding an aggressive approach.
Male predominance across the study participants could be summative effect of the modifiable risk factors – tobacco and/or alcohol consumption – among males besides the inherent gender-related risk. More than half of the patients in the elderly age group and three-fourth in the younger age group were smokers whereas 22.9% and 36.6% consumed alcohol, respectively, similar to other Indian studies. Compared to the elderly, younger patients had significantly higher BMI, low-density lipoprotein, and triglycerides levels concordant with observations of Dang and Dias, Sharma et al., Lavie and Milani, and Sawant et al whereas other conventional risk factors of CAD such as hypertension and diabetes were equally distributed in both age groups like other Indian studies,,, positive family history of CAD had significant association with MI in the young (P = 0.005).
Elderly participants have been conventionally thought to have a risk pattern for cardiovascular mortality different from that of younger people. Risk indicators considered “minor” in the middle-aged person, such as hyperuricemia, ventilatory function, or proteinuria have been reported as having strong predictive value in the elderly. In contrast, the typical risk factors in the young adult, such as hypertension, high cholesterol, or left ventricular hypertrophy, do not seem to have a clear predictive role in the elderly. In the very old participants, the number of risk factors is even smaller, being probably limited to impaired fasting glucose, uric acid, and forced expiratory volume in the 1st second. Elderly participants are likely to be treated for slightly high BP or cholesterol while the important tests might be overlooked.
Acute coronary events were observed with a statistically higher frequency in the younger age group as the number of cardiovascular risk factors increased (P< 0.001). Pereira et al. observed the clustering of two or more risk factors in 71.3% of the 2219 elderly patients in their study. The oldest patients, 80 or more years of age, had smaller clusters when compared to the other age groups. In a separate analysis conducted for the younger and elderly patients, the chance of reporting an ischemic event also increased with a greater number of risk factors. In our study, higher functional class, heart failure, and shock was more common in the elderly than the youngsters similar to the observations by Sharma et al. Single-vessel disease was present in almost half of the younger age group patients when compared to one-third of the elderly and multivessel disease was more common in elderly age group concordant with the study by Galon et al.
In the elderly, coronary angiography is often delayed or prevented due to their poor general condition at presentation and the perception of them being at high risk, in evident contradiction to literature.,, This strategy deprives these patients of the possibility of treatment, as they would have greater benefit in early revascularization, reflected in mortality and/or reinfarction rates. This behavior seems to occur in this study where there was a significant association of age with modality of treatment received. Elderly age group was more likely to be managed conservatively whereas intervention in the form of PCI or CABG was more common in young age group, and the same findings were also observed by Galon et al.
Advanced Killip class, ST-segment deviation, positive initial cardiac enzyme findings have been described as significant predictors of mortality in ACS. In our study, we found that shock, heart failure, higher Killip class on presentation, abnormal electrocardiographic findings, and positive cardiac enzyme findings on presentation were significantly associated with mortality in the elderly (P< 0.001). In contrast to earlier studies, we found that history of old MI was significantly associated with in-hospital mortality in elderly. In this study, multiarterial disease was significantly associated with mortality. Similar findings were observed by Galon et al. in ACS patients undergoing PCI, that were in contrast to another study on patients with ACS presenting with acute pulmonary edema. In addition, there was no statistically significant difference in the in-hospital mortality among those subjected to medical management versus to any intervention. The absence of mortality benefit in the intervention group, consistent with previous studies, might be representative of study size or observations from other reports that most deaths after contemporary percutaneous coronary intervention have noncardiovascular causes.
The limitations of our study were the small number of study participants and overall mortality, nonevaluation of all the conventional and the novel risk factors, and adoption of a conservative approach in those with poor general condition. Despite the limitations, we could conclude that the risk factor profile in the elderly differs from the younger participants with CAD. In addition, we could compare the characteristics of the elderly survivors and nonsurvivors.
The limited health-care delivery resources and unaffordable quality care are the issues that plague the health-care system of India, and judicious allocation of funds for the development of infrastructure for the special population groups is needed to obtain the best outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chaturvedi V, Bhargava B. Health care delivery for coronary heart disease in India – Where are we headed? Am Heart Hosp J 2007;5:32-7.
Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al.
Heart disease and stroke statistics-2017 update: A Report from the American Heart Association. Circulation 2017;135:e146-603.
Franzosi MG, Santoro E, De Vita C, Geraci E, Lotto A, Maggioni AP, et al.
Ten-year follow-up of the first megatrial testing thrombolytic therapy in patients with acute myocardial infarction: Results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'infarto-1 study. The GISSI Investigators. Circulation 1998;98:2659-65.
Enas EA, Chacko V, Pazhoor SG, Chennikkara H, Devarapalli HP. Dyslipidemia in South Asian patients. Curr Atheroscler Rep 2007;9:367-74.
Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part II: Variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation 2001;104:2855-64.
Skolnick AH, Alexander KP, Chen AY, Roe MT, Pollack CV Jr., Ohman EM, et al.
Characteristics, management, and outcomes of 5,557 patients age > or=90 years with acute coronary syndromes: Results from the CRUSADE initiative. J Am Coll Cardiol 2007;49:1790-7.
El-Menyar A, AlHabib KF, Al-Motarreb A, Hersi A, Al Faleh H, Asaad N, et al.
Prior antiplatelet use and cardiovascular outcomes in patients presenting with acute coronary syndromes. Am J Cardiovasc Drugs 2012;12:127-35.
Keller NM, Feit F. Coronary artery disease in the geriatric population. Prog Cardiovasc Dis 1996;38:407-18.
Jaguszewski M, Ghadri JR, Diekmann J, Bataiosu RD, Hellermann JP, Sarcon A, et al.
Acute coronary syndromes in octogenarians referred for invasive evaluation: Treatment profile and outcomes. Clin Res Cardiol 2015;104:51-8.
Bagnall AJ, Goodman SG, Fox KA, Yan RT, Gore JM, Cheema AN, et al.
Influence of age on use of cardiac catheterization and associated outcomes in patients with non-ST-elevation acute coronary syndromes. Am J Cardiol 2009;103:1530-6.
Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al.
Treatment and outcomes of acute coronary syndromes in India (CREATE): A prospective analysis of registry data. Lancet 2008;371:1435-42.
Cannon CP, Brindis RG, Chaitman BR, Cohen DJ, Cross JT Jr., Drozda JP Jr., et al
. 2013 ACCF/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes and coronary artery disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards (Writing committee to develop acute coronary syndromes and coronary artery disease clinical data standards). Crit Pathw Cardiol 2013;12:65-105.
Park K. Park's Textbook of Preventive and Social Medicine. 19 ed. Jabalpur: M/s Banarsidas Bhanot; 2007.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014;37 Suppl 1:S81-90.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr., et al.
The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: The JNC 7 report. JAMA 2003;289:2560-72.
Lorenzo C, Williams K, Hunt KJ, Haffner SM. The National Cholesterol Education Program – Adult Treatment Panel III, International Diabetes Federation, and World Health Organization definitions of the metabolic syndrome as predictors of incident cardiovascular disease and diabetes. Diabetes Care 2007;30:8-13.
Jellinger PS, Handelsman Y, Rosenblit PD, Bloomgarden ZT, Fonseca VA, Garber AJ, et al.
American association of clinical endocrinologists and American College of Endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease. Endocr Pract 2017;23:1-87.
Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, et al.
Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India 2009;57:163-70.
Dang A, Dias A. Differences in risk factors and mortality, in young and old individuals with acute myocardial infarction in Goa. J Clin Diagn Res 2008;2:715-9.
Sharma A, Kumar R, Ashotra S, Thakur S. Comparative evaluation of clinical profile, risk factors, and outcome of acute myocardial infarction in elderly and nonelderly patients. Heart India 2016;4:96-9. [Full text]
Lavie CJ, Milani RV. Adverse psychological and coronary risk profiles in young patients with coronary artery disease and benefits of formal cardiac rehabilitation. Arch Intern Med 2006;166:1878-83.
Sawant AM, Shetty D, Mankeshwar R, Ashavaid TF. Prevalence of dyslipidemia in young adult Indian population. J Assoc Physicians India 2008;56:99-102.
Holay MP, Janbandhu A, Javahirani A, Pandharipande MS, Suryawanshi SD. Clinical profile of acute myocardial infarction in elderly (prospective study). J Assoc Physicians India 2007;55:188-92.
Casiglia E, Palatini P. Cardiovascular risk factors in the elderly. J Hum Hypertens 1998;12:575-81.
Pereira JC, Barreto SM, Passos VM. The profile of cardiovascular health of elderly Brazilian people needs to improve: A population-based study. Arq Bras Cardiol 2008;91:1-0.
Galon MZ, Meireles GC, Kreimer S, Marchiori GG, Favarato D, Almeida JA, et al
. Clinical and angiographic profile in coronary artery disease: Hospital outcome with emphasis on the very elderly. Arq Bras Cardiol 2010;95:422-9.
Spencer FA, Goldberg RJ, Frederick PD, Malmgren J, Becker RC, Gore JM, et al.
Age and the utilization of cardiac catheterization following uncomplicated first acute myocardial infarction treated with thrombolytic therapy (The Second National Registry of Myocardial Infarction [NRMI-2]). Am J Cardiol 2001;88:107-11.
Pilote L, Miller DP, Califf RM, Rao JS, Weaver WD, Topol EJ, et al.
Determinants of the use of coronary angiography and revascularization after thrombolysis for acute myocardial infarction. N
Engl J Med 1996;335:1198-205.
Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al.
ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999-3054.
Tegn N, Abdelnoor M, Aaberge L, Endresen K, Smith P, Aakhus S, et al.
Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After eighty study): An open-label randomised controlled trial. Lancet 2016;387:1057-65.
Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, et al.
Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 2003;163:2345-53.
Motivala AA, Tamhane U, Ramanath VS, Saab F, Montgomery DG, Fang J, et al.
Aprior myocardial infarction: How does it affect management and outcomes in recurrent acute coronary syndromes? Clin Cardiol 2008;31:590-6.
Figueras J, Bañeras J, Peña-Gil C, Barrabés JA, Rodriguez Palomares J, Garcia Dorado D, et al.
Hospital and 4-year mortality predictors in patients with acute pulmonary edema with and without coronary artery disease. J Am Heart Assoc 2016;5. pii: e002581.
Spoon DB, Psaltis PJ, Singh M, Holmes DR Jr., Gersh BJ, Rihal CS, et al.
Trends in cause of death after percutaneous coronary intervention. Circulation 2014;129:1286-94.
[Table 1], [Table 2]