About two-thirds of patients older than 65 who experience a myocardial infarction (MI) die within eight years, according to a new study—and nearly half die in that timeframe even if they receive percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery.
“From a healthcare perspective, these statistics are sobering,” lead author Ajar Kochar, MD, with Duke Clinical Research Institute, and colleagues wrote in the Journal of the American Heart Association. “These findings should lead to reflections on appropriate utilization and optimal dosing of secondary prevention therapies, along with revascularization when indicated for older patients with MI. Novel medication approaches to secondary prevention may be of particular interest to older patients with MI.”
The analysis contained almost 23,000 patients from the CRUSADE registry who were treated at 344 U.S. hospitals from 2004 to 2006. Patients were a median of 77 years old at baseline, 52.5 percent were male and 13.3 percent were nonwhite.
In the overall cohort, the median survival was 4.8 years, including 8.2 years for those aged 65 to 74 and 3.1 years for people over 75. Eight-year mortality rates were 65 percent overall, 49 percent for those undergoing PCI and 46 percent for CABG patients.
Kochar et al. hope these findings can help educate patients about their expected long-term prognoses. Long-term outcomes of older heart attack patients are understudied, the authors added, because they’re often excluded from clinical trials and many other trials don’t have follow-up beyond the first few years after the index event.
“The mortality of patients treated in routine community practice is likely worse than those of patients typically included in randomized trial populations, regardless of revascularization status,” the authors wrote. “Armed with these data, patients and clinicians can have more meaningful conversations about post‐MI prognosis and more optimally engage in shared decision making, especially as observed survival in post‐MI patients was markedly lower than actuarial survival among similarly aged U.S. adults.”
Indeed, data from the United States National Vital Statistics Reports shows the median life expectancy of non-MI individuals aged 65-69 is 18.7 years, while it’s just 8.3 years for those who have suffered a heart attack. At every age range above that, the life expectancy of people who haven’t had a heart attack is at least twice that of heart attack survivors—although the absolute difference in years decreases with older age as life expectancies in both groups shrink.
Potential explanations for the high mortality in this study include older patients presenting later for medical care as a result of atypical symptoms or cognitive decline, plus the higher likelihood of post-treatment frailty.
“Underutilization of evidence‐based therapies has been well described among older patients with MI,” Kochar et al. added. “While evidence‐based medications were prescribed at high rates at the time of discharge, our data could not examine medication dosing, persistence, and adherence over the study period. Prior studies demonstrated suboptimal adherence to statins among older patients with MI, and low medication adherence was associated with a higher risk of major cardiovascular events.”
The authors pointed out long-term data from a study that ended in 2006 may not reflect contemporary prognoses, although they said revascularization rates among older MI patients haven’t changed much in the current era. In addition, more powerful antiplatelet agents and newer stent technologies weren’t yet available during this study, and those improvements in care may have improved outcomes.