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“These findings
demonstrate the
cost of a missed
opportunity
when eligible
patients are not
treated.”
Long-lasting Survival Benefits of
Guideline-directed Care in Older MI
Patients
Acute myocardial infarction (AMI)
patients who receive guideline-based
admission treatments have a longer
life expectancy, according to a study
published April 18 in JACC.
The study, led by Emily M.
Bucholz, MD, PhD, MPH, evaluated
data from the Cooperative Cardiovascular Project (CCP) to determine
the relationship between five AMI
guidelines with long-term survival
and life expectancy after AMI in
elderly patients over the age of 65.
The five AMI guidelines are aspirin
on admission, beta-blockers on admission, acute reperfusion therapy, doorto-balloon (D2B) within 90 minutes
and door-to-needle (D2N) within 30
minutes of arrival.
A total of 147,429 patients were
eligible for at least one therapy, with
72.5% eligible for aspirin and 44.7%
eligible for beta-blockers. These patients were more likely to be younger
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and have ST-elevation AMIs than
those who were not. Of the 19,949
patients eligible for acute reperfusion
therapy, 56.3% received either percutaneous coronary intervention (PCI)
or fibrinolytic therapy.
The researchers reported that survival curves of patients receiving and
not receiving each therapy separated
almost immediately after admission
for all five guidelines, remaining
distinct throughout the trial period.
Those undergoing recommended therapies had significantly lower mortality rates at all times during the study.
For all therapies, treated patients had
significantly longer life expectancies.
After adjustment, aspirin was associated with an average of 0.65 years
of life saved, beta-blockers with 0.45
years, and acute reperfusion therapy
with 0.90 years. The absolute number
of life-years saved was greater in
younger patients for these guidelines,
but the percentage of life-years saved
was similar across all age groups.
Patients who took aspirin,
beta-blockers, and acute reperfusion
therapy on admission were significantly more likely to receive the same
therapy at discharge, which in turn
improved survival. Additionally, those
with shorter D2B and D2N times had
longer life expectancy.
The results, noted the authors,
“provide evidence that intensifies the
support for these rapid treatments
and estimates what is likely lost by
the omission, thereby strengthening
the imperative to treat appropriate
patients.” They added that when the
CCP was first implemented in the
mid-1990s, rates of patients who received these guideline-based therapies
were much lower than they are today
(764 years of life could have been
saved by aspirin treatment, 15,065
years by beta-blockers and 764 years
by shortening D2B times if the rates
were what they are today).
“These findings demonstrate the
cost of a missed opportunity when
eligible patients are not treated,” they
wrote.
Meanwhile, while public reporting
and pay for performance initiatives
have improved the quality of AMI
care in the United States, many other
countries have not implemented
the same quality measures. Rates of
patients receiving these therapies
vary greatly in countries throughout
the world. Thomas A. Gaziano, MD,
MSc, commented on this disparity
in an accompanying JACC editorial,
noting that in 2011, the United Nations set a goal of reducing the rates
on non-communicable diseases by
25% by 2025. Cardiovascular disease
(CVD) represents more than half of
these deaths.
“While many countries are not
currently providing [PCIs] for the vast
majority of the population, they are
providing all the other acute myocardial infarction therapies,” Dr. Gaziano
wrote. “Knowledge that timely and
ready access to all other treatments
can have both immediate and long
term benefits could go a long way to
achieving the goal.”
Bucholz EM, Butala NM, Normand, SLT, et
al. J Am Coll Cardiol. 2016;doi:10.1016/j.
jacc.2016.03.507.
Statement Calls
for More Clinical
Trials that Include
Elderly Adults
There is a critical need for an increased number of large, populationbased studies and clinical trials that
include adults older than 75 years
with complex comorbidities and other
issues, according to a scientific statement released April 11 by the ACC, in
conjunction with the American Heart
Association (AHA) and the American
Geriatrics Society, and published in
JACC.
May 2016