Abstract

Aims

To examine age-dependent in-hospital mortality for hospitalization with acute coronary syndromes (ACS) in England and Wales.

Methods and results

Mixed-effects regression analysis using data from 616 011 ACS events at 255 hospitals as recorded in the Myocardial Ischemia National Audit Project (MINAP) 2003–2010; 102 415 (16.7%) patients were aged <55 years and 72 721 (11.9%) ≥85 years. Patients ≥85 years with ST-elevation myocardial infarction (STEMI) were less likely to receive emergency reperfusion therapy than those <55 years (RR = 0.27, 95% CI: 0.25–0.28). Older patients had greater lengths of stay (P< 0.001) and higher in-hospital mortality (P< 0.001). For STEMI and non-ST-elevation myocardial infarction (NSTEMI), there were reductions in in-hospital mortality from 2003 to 2010 across all age groups including the very elderly. For STEMI ≥ 85 years, in-hospital mortality reduced from 30.1% in 2003 to 19.4% in 2010 (RR = 0.54, 95% CI: 0.38–0.75, P< 0.001), and for NSTEMI ≥ 85 years, from 31.5% in 2003 to 20.4% in 2010 (RR = 0.56, 95% CI: 0.42–0.73, P< 0.001). Findings were upheld after multi-level adjustment (base = 2003): male STEMI 2010 OR = 0.60, 95% CI: 0.48–0.75; female STEMI 2010 OR = 0.55, 95% CI: 0.42–0.71; male NSTEMI OR = 0.50, 95% CI: 0.42–0.60; female NSTEMI OR = 0.49, 95% CI: 0.40–0.59.

Conclusion

For patients hospitalized with ACS in England and Wales, there have been substantial reductions in in-hospital mortality rates from 2003 to 2010 across all age groups. The temporal improvements in mortality were similar for sex and type of acute myocardial infarction. Age-dependent inequalities in the management of ACS were apparent.

See page 562 for the editorial comment on this article (doi:10.1093/eurheartj/ehr364)

Introduction

Data from international studies suggest that elderly patients who are admitted to hospital with an acute coronary syndrome (ACS) are less likely to receive evidence-based care and that they have higher mortality rates than their younger counterparts.1–7 Recently, however, there have been substantial improvements in the treatment and outcome of ACS among a range of developed and developing countries.8,9 In part, this has been attributed to increased use of evidence-based ACS therapies.8–11 For the elderly, it has been advocated that improvements in hospital care may translate into a reduction in mortality and research has highlighted the need for quality-of-care programmes that reinforce the use of evidence-based therapies among this group.2

With the advent of the new definition of acute myocardial infarction (AMI) and a greater emphasis placed on the results of the cardiac troponin concentration,12 a contemporary analysis of patients admitted to hospital with an ACS may reveal a changing burden of disease and early outcomes. Moreover, it is not known whether the effects of reported improvements in ACS care have occurred equally across the spectrum of ACS ages. This study, therefore, aimed to (i) establish whether, in light of international recommendations,13,14 age-dependent inequalities in care continue to exist in a modern national healthcare system and (ii) quantify and compare temporal effects in in-hospital mortality by age for patients who present to hospital with an ACS.

Methods

Study design

The analyses were based on data from the Myocardial Ischaemia National Audit Project (MINAP) whose national database was established in 1999 to examine the quality of management of AMI in England and Wales and to meet the audit requirements of the National Service Framework (NSF) for Coronary Heart Disease.15–18 MINAP data collection and management has previously been described.19,20

Data for patients admitted with an ACS are collected prospectively at each acute hospital by a secure electronic system, developed by the Central Cardiac Audit Database (CCAD), electronically encrypted and transferred online to a central database.21 CCAD is part of the National Institute for Cardiovascular Outcomes Research (NICOR) based at University College London. MINAP is overseen by a multi-professional steering group representing the stakeholders.16

Each patient entry offers details of the patient journey, including the method and timing of admission, inpatient investigations, treatment, and date of all-cause death [from linkage to the National Health Service Central Register (NHSCR) using a unique National Health Service (NHS) number]. Data entry is subject to routine online error checking. There is a mandatory annual data validation exercise for each hospital.22

Cohort description

The investigators had access to data in which patient identity was protected. The MINAP cohort comprised 616 011 index patient events admitted to 238 acute hospitals in England and 17 acute hospitals in Wales between 1 January 2003 and 2 October 2010.

Ages on admission were categorized into five groups: <55 years, 55–64 years, 65–74 years, 75–84 years, and ≥85 years of age. The initial diagnosis was based on the working diagnosis generated by a paramedic or first attending physician who was in a position to provide definitive treatment. The final diagnosis was formed from the patients' presenting history, clinical examination and the results of inpatient investigations, and made by a senior member of the medical staff. The consensus document of the Joint European Society of Cardiology/American College of Cardiology23 was used as the diagnostic standard for AMI and provided the basis for categorization into ST-elevation myocardial infarction (STEMI). Non-ST-elevation acute coronary syndrome (NSTEACS) was defined as a troponin positive [non-ST-elevation myocardial infarction (NSTEMI)] or troponin negative (unstable angina) ACS.

Statistical methods

The population was described without adjustment and by percentages with respect to discrete data, and by medians and interquartile range or mean and 95% range for continuous variables. Pearson's χ2 test was used to determine whether there was a significant difference between the expected frequencies and the observed frequencies in one or more categories. The Kruskall–Wallis rank test was used to test the difference in distributions across groups. The analysis of variance test was use to ascertain whether the means of several groups were all equal.

Given that there was a significant interaction between age, in-hospital mortality, and sex for STEMI (P< 0.001) and NSTEMI (P< 0.001), models were fitted by sex. To account for variations at the hospital level, a linear mixed-effects regression model was used to quantify the relationship between age category and ACS final diagnosis at discharge from hospital, and between age category and in-hospital all-cause mortality. The model fitted included age, history of diabetes, hypertension, previous AMI, angina, history of heart failure, previous revascularization [percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG)], admitting consultant, admission ward, and emergency reperfusion (primary PCI and/or thrombolysis). The temporal risk of in-hospital mortality was quantified by STEMI and NSTEMI after adjustment for age category and consideration of hospital random effects. Finally, the risk of in-hospital mortality was estimated for each age category after adjustment for the final diagnosis and consideration of hospital random effects. We used STATA IC version 11.0 (Stat Corp LP, TX, USA) for the analyses.

Results

Of the 616 011 patients, 102 415 (16.7%) were <55 years and 72 721 (11.9%) were ≥85 years of age. Data for age were missing for 4.2% of men and 4.5% of women, and in-hospital status was missing for 5.6% of the cohort. The proportion of men reduced from 79.4% among patients aged <55 years to 41.9% among patients aged ≥85 years (Table 1). There were 208 358 (33.8%) patients with a final diagnosis of STEMI, 325 299 (52.8%) NSTEACS, 24 320 (3.9%) unconfirmed ACS, 35 783 (5.8%) non-ACS/other, and 19 217 (3.1%) with a missing final diagnosis.

Table 1

Baseline clinical characteristics Myocardial Ischemia National Audit Project patients (all acute coronary syndrome diagnoses combined) by age group

Age group (years) <55, % (n55–64, % (n65–74, % (n75–84, % (n≥85, % (nTotals, % (n
Men 81 310 86 660 94 668 85 741 30 464 395 464 
Women 21 105 27 816 48 164 68 391 42 257 217 513 
Diabetes 
 Men 10.1 (8224) 14.3 (12 412) 19.9 (18 878) 19.8 (16 953) 15.7 (4771) 16.1 (63 592) 
 Women 13.6 (2867) 16.2 (4508) 20.7 (9962) 19.0 (12 986) 13.6 (5742) 17.2 (37 507) 

 
Hypertension 
 Men 27.2 (22 086) 37.3 (32 315) 43.7 (41 378) 45.9 (39 394) 44.0 (13 403) 38.9 (153 969) 
 Women 31.0 (6534) 42.2 (11 751) 48.9 (23 535) 52.3 (35 768) 49.2 (20 777) 46.9 (102 094) 

 
Current smoker 
 Men 52.6 (42 791) 36.6 (31 748) 20.9 (19 762) 10.9 (9361) 6.2 (1880) 27.7 (109 362) 
 Women 47.4 (10 009) 36.1 (10 032) 21.5 (10 349) 10.9 (7452) 3.6 (1534) 18.8 (40 955) 

 
Prior AMI 
 Men 15.2 (12 324) 20.9 (18 135) 28.1 (26 591) 33.3 (28 525) 35.0 (10 668) 25.3 (100 186) 
 Women 11.9 (2504) 15.5 (4307) 21.6 (10 420) 26.4 (18 078) 27.1 (11 440) 22.3 (48 541) 

 
Angina 
 Men 15.4 (12 498) 23.2 (20 123) 32.2 (30 460) 39.1 (33 525) 42.2 (12 860) 28.8 (113 935) 
 Women 17.0 (3592) 23.2 (6462) 30.3 (14 594) 35.5 (24 272) 35.9 (15 150) 30.7 (66 725) 

 
Prior revascularization 
 Men 10.4 (8429) 14.1 (12 246) 17.2 (16 313) 14.5 (12 390) 6.7 (2053) 13.5 (53 520) 
 Women 7.8 (1641) 10.0 (2786) 11.4 (5505) 8.2 (5642) 3.0 (1288) 8.0 (17 506) 

 
Chronic heart failure 
 Men 1.1 (890) 2.3 (1961) 4.8 (4543) 8.4 (7202) 12.1 (3686) 4.8 (19 060) 
 Women 1.3 (273) 2.4 (665) 5.0 (2418) 8.9 (6053) 12.4 (5237) 7.0 (15 252) 

 
Chronic renal failure 
 Men 1.1 (869) 1.7 (1514) 3.7 (3456) 6.8 (5795) 9.5 (2901) 3.8 (15 216) 
 Women 1.5 (325) 2.0 (544) 3.2 (1559) 4.8 (3307) 5.8 (2450) 3.9 (8558) 
Age group (years) <55, % (n55–64, % (n65–74, % (n75–84, % (n≥85, % (nTotals, % (n
Men 81 310 86 660 94 668 85 741 30 464 395 464 
Women 21 105 27 816 48 164 68 391 42 257 217 513 
Diabetes 
 Men 10.1 (8224) 14.3 (12 412) 19.9 (18 878) 19.8 (16 953) 15.7 (4771) 16.1 (63 592) 
 Women 13.6 (2867) 16.2 (4508) 20.7 (9962) 19.0 (12 986) 13.6 (5742) 17.2 (37 507) 

 
Hypertension 
 Men 27.2 (22 086) 37.3 (32 315) 43.7 (41 378) 45.9 (39 394) 44.0 (13 403) 38.9 (153 969) 
 Women 31.0 (6534) 42.2 (11 751) 48.9 (23 535) 52.3 (35 768) 49.2 (20 777) 46.9 (102 094) 

 
Current smoker 
 Men 52.6 (42 791) 36.6 (31 748) 20.9 (19 762) 10.9 (9361) 6.2 (1880) 27.7 (109 362) 
 Women 47.4 (10 009) 36.1 (10 032) 21.5 (10 349) 10.9 (7452) 3.6 (1534) 18.8 (40 955) 

 
Prior AMI 
 Men 15.2 (12 324) 20.9 (18 135) 28.1 (26 591) 33.3 (28 525) 35.0 (10 668) 25.3 (100 186) 
 Women 11.9 (2504) 15.5 (4307) 21.6 (10 420) 26.4 (18 078) 27.1 (11 440) 22.3 (48 541) 

 
Angina 
 Men 15.4 (12 498) 23.2 (20 123) 32.2 (30 460) 39.1 (33 525) 42.2 (12 860) 28.8 (113 935) 
 Women 17.0 (3592) 23.2 (6462) 30.3 (14 594) 35.5 (24 272) 35.9 (15 150) 30.7 (66 725) 

 
Prior revascularization 
 Men 10.4 (8429) 14.1 (12 246) 17.2 (16 313) 14.5 (12 390) 6.7 (2053) 13.5 (53 520) 
 Women 7.8 (1641) 10.0 (2786) 11.4 (5505) 8.2 (5642) 3.0 (1288) 8.0 (17 506) 

 
Chronic heart failure 
 Men 1.1 (890) 2.3 (1961) 4.8 (4543) 8.4 (7202) 12.1 (3686) 4.8 (19 060) 
 Women 1.3 (273) 2.4 (665) 5.0 (2418) 8.9 (6053) 12.4 (5237) 7.0 (15 252) 

 
Chronic renal failure 
 Men 1.1 (869) 1.7 (1514) 3.7 (3456) 6.8 (5795) 9.5 (2901) 3.8 (15 216) 
 Women 1.5 (325) 2.0 (544) 3.2 (1559) 4.8 (3307) 5.8 (2450) 3.9 (8558) 

Cardiovascular risk factors

The distribution of baseline risk factors varied by age groups and sex (Table 1). Older patients were less often current smokers and more often had hypertension, prior AMI, angina, chronic heart failure and chronic renal failure. Compared with men ≥85 years, women ≥85 years of age were less often current smokers. They less often had diabetes, previous AMI, angina, previous revacularization (PCI or CABG), and chronic renal failure.

Diagnoses, presentation, and provision of care

Table 2 shows the distribution of initial and final diagnoses, method of presentation, and provision of care by age group. Younger patients more often had an initial diagnosis of STEMI. Older patients more often had a final diagnosis of NSTEACS. Compared with men ≥85 years of age, women ≥85 years of age less often had an initial diagnosis of NSTEACS. Older patients were less likely to call the emergency services or make their own way to the hospital, and more likely to have an ACS in hospital than their younger counterparts. Also, older patients were less likely to be admitted to the Cardiac Care Unit, a Cardiology ward, and be under the care of a Consultant Cardiologist. For STEMI and NSTEMI, the proportion of patients ≥85 years of age with cardiogenic shock was higher than that for patients <55 years of age: STEMI: <55 years = 2.1%, ≥85 years = 5.0%, P< 0.001; NSTEMI: <55 years = 1.2%, ≥85 years = 3.1%, P< 0.001.

Table 2

Initial and final acute coronary syndrome diagnoses, method of presentation and provision of care by age group

Age group <55, % (n55–64, % (n65–74, % (n75–84, % (n≥85, % (nMissing age, % (nTotals, % (n
Men 81 310 86 660 94 668 85 741 30 464 16 621 395 464 
Women 21 105 27 816 48 164 68 391 42 257 9780 217 513 
Initial diagnosis 
 STEMI 
  Men 37.8 (30 709) 35.6 (30 841) 27.7 (26 265) 20.1 (17 250) 13.9 (4229) 19.1 (3182) 28.4 (112 476) 
  Women 25.7 (5433) 26.8 (7458) 23.9 (11 494) 19.0 (13 013) 15.0 (6324) 13.8 (1345) 20.7 (45 067) 
 NSTEACS        
  Men 39.5 (32 152) 42.8 (37 123) 45.1 (42 687) 44.8 (38 403) 43.5 (13 244) 40.5 (6734) 43.1 (170 343) 
  Women 41.5 (8767) 44.3 (12 331) 43.8 (21 082) 42.1 (28 824) 38.6 (16 318) 37.7 (3687) 41.8 (91 009) 

 
Final diagnosis 
 STEMI 
  Men 45.9 (37 313) 44.3 (38 376) 36.4 (34 449) 28.3 (24 244) 21.8 (6633) 24.7 (4113) 36.7 (145 128) 
  Women 32.9 (6952) 34.7 (9663) 32.1 (15 473) 27.9 (19 106) 23.9 (10 081) 20.0 (1955) 29.1 (63 230) 
 NSTEACS 
  Men 37.7 (30 690) 45.1 (39 063) 52.7 (49 886) 61.3 (52 541) 68.7 (20 926) 51.0 (8473) 51.0 (201 579) 
  Women 42.3 (8931) 49.3 (13 706) 54.7 (26 338) 60.7 (41 541) 66.2 (27 973) 53.5 (5231) 56.9 (123 720) 

 
Presentation and provision of care—all ACS 
 Called emergency services 
  Men 50.7 (41 228) 54.7 (47 383) 59.7 (56 475) 64.8 (55 594) 68.6 (208 99) 32.7 (5436) 57.4 (227 015) 
  Women 49.7 (10 488) 54.5 (15 150) 59.3 (28 557) 64.8 (44 317) 68.1 (28 784) 34.6 (3381) 60.1 (130 677) 
 Made own way to hospital 
  Men 25.7 (20 913) 19.7 (17 065) 13.3 (12 621) 7.6 (6518) 4.1 (1239) 11.5 (1914) 15.2 (60 270) 
  Women 22.7 (4785) 17.6 (4897) 11.7 (5628) 6.2 (4268) 3.4 (1434) 7.9 (774) 10.0 (21 786) 
 Already in hospital 
  Men 1.7 (1403) 2.5 (2184) 4.1 (3838) 6.0 (5104) 7.1 (2175) 12.6 (2096) 4.2 (16 800) 
  Women 2.9 (615) 3.4 (952) 4.9 (2368) 6.6 (4544) 7.7 (3244) 16.1 (1571) 6.1 (13 294) 
 First ward: Cardiac Care Unit 
  Men 66.1 (53 780) 63.1 (54 709) 57.2 (54 318) 49.0 (42 054) 38.9 (11 858) 43.3 (7203) 56.6 (223 922) 
  Women 59.1 (12 471) 56.8 (15 793) 52.8 (25 423) 45.1 (30 816) 35.1 (14 823) 36.9 (3610) 47.3 (102 936) 
 First ward: Cardiology 
  Men 4.8 (3901) 5.5 (4779) 5.8 (5472) 5.8 (4958) 5.8 (1781) 4.7 (784) 5.5 (21 675) 
  Women 5.0 (1056) 5.7 (1579) 5.8 (2780) 5.5 (3771) 5.2 (2193) 3.9 (375) 5.4 (11 754) 
 Admitting consultant: Cardiologist 
  Men 50.1 (40 729) 48.0 (41 627) 44.0 (41 637) 36.8 (31 561) 28.5 (8689) 38.3 (6365) 43.1 (170 608) 
  Women 47.1 (9950) 44.5 (12 372) 42.0 (20 229) 34.0 (23 285) 25.1 (10 609) 33.1 (3238) 36.6 (79 683) 
Age group <55, % (n55–64, % (n65–74, % (n75–84, % (n≥85, % (nMissing age, % (nTotals, % (n
Men 81 310 86 660 94 668 85 741 30 464 16 621 395 464 
Women 21 105 27 816 48 164 68 391 42 257 9780 217 513 
Initial diagnosis 
 STEMI 
  Men 37.8 (30 709) 35.6 (30 841) 27.7 (26 265) 20.1 (17 250) 13.9 (4229) 19.1 (3182) 28.4 (112 476) 
  Women 25.7 (5433) 26.8 (7458) 23.9 (11 494) 19.0 (13 013) 15.0 (6324) 13.8 (1345) 20.7 (45 067) 
 NSTEACS        
  Men 39.5 (32 152) 42.8 (37 123) 45.1 (42 687) 44.8 (38 403) 43.5 (13 244) 40.5 (6734) 43.1 (170 343) 
  Women 41.5 (8767) 44.3 (12 331) 43.8 (21 082) 42.1 (28 824) 38.6 (16 318) 37.7 (3687) 41.8 (91 009) 

 
Final diagnosis 
 STEMI 
  Men 45.9 (37 313) 44.3 (38 376) 36.4 (34 449) 28.3 (24 244) 21.8 (6633) 24.7 (4113) 36.7 (145 128) 
  Women 32.9 (6952) 34.7 (9663) 32.1 (15 473) 27.9 (19 106) 23.9 (10 081) 20.0 (1955) 29.1 (63 230) 
 NSTEACS 
  Men 37.7 (30 690) 45.1 (39 063) 52.7 (49 886) 61.3 (52 541) 68.7 (20 926) 51.0 (8473) 51.0 (201 579) 
  Women 42.3 (8931) 49.3 (13 706) 54.7 (26 338) 60.7 (41 541) 66.2 (27 973) 53.5 (5231) 56.9 (123 720) 

 
Presentation and provision of care—all ACS 
 Called emergency services 
  Men 50.7 (41 228) 54.7 (47 383) 59.7 (56 475) 64.8 (55 594) 68.6 (208 99) 32.7 (5436) 57.4 (227 015) 
  Women 49.7 (10 488) 54.5 (15 150) 59.3 (28 557) 64.8 (44 317) 68.1 (28 784) 34.6 (3381) 60.1 (130 677) 
 Made own way to hospital 
  Men 25.7 (20 913) 19.7 (17 065) 13.3 (12 621) 7.6 (6518) 4.1 (1239) 11.5 (1914) 15.2 (60 270) 
  Women 22.7 (4785) 17.6 (4897) 11.7 (5628) 6.2 (4268) 3.4 (1434) 7.9 (774) 10.0 (21 786) 
 Already in hospital 
  Men 1.7 (1403) 2.5 (2184) 4.1 (3838) 6.0 (5104) 7.1 (2175) 12.6 (2096) 4.2 (16 800) 
  Women 2.9 (615) 3.4 (952) 4.9 (2368) 6.6 (4544) 7.7 (3244) 16.1 (1571) 6.1 (13 294) 
 First ward: Cardiac Care Unit 
  Men 66.1 (53 780) 63.1 (54 709) 57.2 (54 318) 49.0 (42 054) 38.9 (11 858) 43.3 (7203) 56.6 (223 922) 
  Women 59.1 (12 471) 56.8 (15 793) 52.8 (25 423) 45.1 (30 816) 35.1 (14 823) 36.9 (3610) 47.3 (102 936) 
 First ward: Cardiology 
  Men 4.8 (3901) 5.5 (4779) 5.8 (5472) 5.8 (4958) 5.8 (1781) 4.7 (784) 5.5 (21 675) 
  Women 5.0 (1056) 5.7 (1579) 5.8 (2780) 5.5 (3771) 5.2 (2193) 3.9 (375) 5.4 (11 754) 
 Admitting consultant: Cardiologist 
  Men 50.1 (40 729) 48.0 (41 627) 44.0 (41 637) 36.8 (31 561) 28.5 (8689) 38.3 (6365) 43.1 (170 608) 
  Women 47.1 (9950) 44.5 (12 372) 42.0 (20 229) 34.0 (23 285) 25.1 (10 609) 33.1 (3238) 36.6 (79 683) 

Management and in-hospital mortality

Table 3 shows the distribution of evidence-based management and outcomes by age category. For all ACS combined, older patients had greater lengths of stay (df = 5, P< 0.001) and higher in-hospital mortality rates (P< 0.001). For those with an initial diagnosis of STEMI, older patients were less likely to receive primary PCI, pre-hospital thrombolysis, and to a lesser extent in-hospital thrombolysis. They too had greater lengths of stay (df = 5, P< 0.001) and higher in-hospital mortality rates (df = 5, P< 0.001). Patients ≥85 years of age with an initial diagnosis of STEMI were up to 75% less likely to be reperfused (by either primary PCI or thrombolysis) compared with those <55 years of age with STEMI: RR = 0.27, 95% CI: 0.25–0.28.

Table 3

Management and outcome by age group and acute coronary syndrome subgroups

Age group <55, % (n55–64, % (n65–74, % (n75–84, % (n≥85, % (nMissing age, % (nTotals 
Men 81 310 86 660 94 668 85 741 30 464 16 621 395 464 
Women 21 105 27 816 48 164 68 391 42 257 9780 217 513 
All ACS 
 Median length of hospital stay (IQR) 
  Men 4 (5) 5 (5) 6 (7) 7 (8) 7 (10) 5 (5) 5 (6) 
  Women 4 (5) 5 (5) 6 (6) 7 (9) 8 (11) 6 (8) 6 (8) 
 In-hospital mortality 
  Men 1.3 (1070) 2.5 (2161) 5.6 (5296) 11.8 (10 141) 19.7 (6004) 7.4 (1224) 6.6 (25 996) 
  Women 1.7 (360) 3.2 (888) 6.5 (3151) 12.7 (8660) 20.3 (8570) 10.8 (1053) 10.4 (22 682) 

 
Patients with an initial diagnosis is STEMI 
 Primary PCI 
  Men 24.3 (7470) 21.1 (6509) 19.5 (5123) 17.3 (2992) 15.1 (640) 8.8 (280) 20.5 (23 014) 
  Women 23.7 (1287) 20.6 (1534) 19.3 (2223) 16.7 (2174) 13.4 (849) 6.5 (88) 18.1 (8155) 
 Pre-hospital thrombolysis 
  Men 11.8 (3644) 12.9 (3973) 11.7 (3072) 7.1 (1221) 2.4 (102) 1.6 (50) 10.7 (12 062) 
  Women 9.5 (516) 11.3 (840) 9.6 (1102) 5.6 (734) 1.7 (106) 1.3 (17) 7.4 (3315) 
 In-hospital thrombolysis 
  Men 52.6 (16 175) 53.8 (16 607) 54.3 (14 253) 54.7 (9442) 52.8 (2233) 49.6 (1580) 53.6 (60 290) 
  Women 53.7 (2920) 55.1 (4112) 54.4 (6256) 54.5 (7091) 50.2 (3172) 44.8 (603) 53.6 (24 154) 
 Median length of hospital stay (IQR) 
  Men 4 (3) 5 (4) 5 (5) 6 (7) 6 (9) 5 (5) 5 (5) 
  Women 5 (4) 5 (4) 6 (5) 6 (7) 7 (10) 6 (6) 6 (7) 
 In-hospital mortality 
  Men 1.5 (467) 2.6 (815) 6.2 (1625) 14.0 (2423) 24.5 (1035) 5.5 (174) 5.8 (6539) 
  Women 2.3 (126) 4.2 (313) 8.2 (944) 17.2 (2232) 28.9 (1827) 14.1 (189) 12.5 (5631) 

 
Patients with a final diagnosis is AMI (NSTEMI + STEMI) 
 Aspirin on discharge 
  Men 79.1 (48 675) 77.9 (55 083) 74.6 (57 505) 70.2 (50 171) 66.5 (17 508) 73.5 (8210) 74.5 (237 152) 
  Women 77.0 (10 690) 77.2 (16 011) 74.0 (27 850) 69.6 (38 934) 65.5 (23 562) 68.3 (4373) 77.0 (214 905) 
 Clopidogrel on discharge 
  Men 36.7 (22 566) 35.7 (25 230) 32.5 (25 031) 29.9 (21 343) 28.5 (7509) 22.9 (2557) 32.7 (104 236) 
  Women 36.0 (4992) 35.3 (7331) 32.0 (12 048) 29.4 (16 463) 25.7 (9255) 19.4 (1241) 30.1 (51 330) 
 β-Blocker on discharge 
  Men 71.9 (44 265) 68.3 (48 266) 61.3 (47 285) 53.6 (38 327) 46.0 (12 108) 60.1 (6709) 61.9 (196 960) 
  Women 64.3 (8925) 63.1 (13 084) 58.3 (21 917) 53.3 (29 843) 46.3 (16 642) 50.7 (3249) 54.9 (93 660) 
 ACE inhibitor on discharge 
  Men 70.1 (43 168) 69.6 (49 228) 66.2 (51 016) 59.4 (42 504) 49.4 (13 021) 61.7 (6886) 64.7 (205 823) 
  Women 63.4 (8792) 65.4 (13 565) 63.7 (23 979) 58.5 (32 743) 48.1 (17 286) 53.4 (3421) 58.5 (99 786) 
 Statin on discharge 
  Men 78.4 (48 261) 78.0 (55 116) 75.5 (58 154) 70.4 (50 344) 61.3 (16 131) 72.3 (8072) 74.2 (236 078) 
  Women 76.0 (10 545) 77.1 (15 986) 74.9 (28 181) 69.6 (38 920) 56.2 (20 224) 63.9 (4093) 69.2 (117 949) 
 Coronary angiography 
  Men 56.7 (34 883) 51.1 (36 119) 43.6 (33 577) 27.5 (19 654) 12.1 (3196) 34.3 (3831) 41.2 (131 260) 
  Women 53.9 (7485) 47.5 (9850) 38.7 (14 567) 22.5 (12 592) 8.8 (3153) 24.0 (1535) 28.8 (49 182) 
 Echocardiography 
  Men 48.7 (29 987) 48.9 (34 557) 49.6 (38 257) 48.6 (34 781) 41.3 (10 872) 46.4 (5182) 48.3 (153 636) 
  Women 49.2 (6823) 48.4 (10 036) 49.5 (18 642) 48.2 (26 941) 38.2 (13 728) 42.9 (2745) 46.3 (78 915) 
 Median length of hospital stay (IQR) 
  Men 5 (4) 5 (5) 6 (6) 7 (8) 7 (9) 6 (5) 6 (6) 
  Women 5 (4) 5 (5) 6 (7) 7 (9) 8 (11) 7 (8) 7 (8) 
 In-hospital mortality 
  Men 1.3 (824) 2.6 (1872) 5.6 (4506) 12.0 (8894) 19.7 (5329) 8.0 (940) 6.8 (22 365) 
  Women 1.9 (276) 3.5 (747) 6.9 (2704) 13.2 (7674) 20.6 (7700) 12.8 (861) 11.3 (19 962) 
Age group <55, % (n55–64, % (n65–74, % (n75–84, % (n≥85, % (nMissing age, % (nTotals 
Men 81 310 86 660 94 668 85 741 30 464 16 621 395 464 
Women 21 105 27 816 48 164 68 391 42 257 9780 217 513 
All ACS 
 Median length of hospital stay (IQR) 
  Men 4 (5) 5 (5) 6 (7) 7 (8) 7 (10) 5 (5) 5 (6) 
  Women 4 (5) 5 (5) 6 (6) 7 (9) 8 (11) 6 (8) 6 (8) 
 In-hospital mortality 
  Men 1.3 (1070) 2.5 (2161) 5.6 (5296) 11.8 (10 141) 19.7 (6004) 7.4 (1224) 6.6 (25 996) 
  Women 1.7 (360) 3.2 (888) 6.5 (3151) 12.7 (8660) 20.3 (8570) 10.8 (1053) 10.4 (22 682) 

 
Patients with an initial diagnosis is STEMI 
 Primary PCI 
  Men 24.3 (7470) 21.1 (6509) 19.5 (5123) 17.3 (2992) 15.1 (640) 8.8 (280) 20.5 (23 014) 
  Women 23.7 (1287) 20.6 (1534) 19.3 (2223) 16.7 (2174) 13.4 (849) 6.5 (88) 18.1 (8155) 
 Pre-hospital thrombolysis 
  Men 11.8 (3644) 12.9 (3973) 11.7 (3072) 7.1 (1221) 2.4 (102) 1.6 (50) 10.7 (12 062) 
  Women 9.5 (516) 11.3 (840) 9.6 (1102) 5.6 (734) 1.7 (106) 1.3 (17) 7.4 (3315) 
 In-hospital thrombolysis 
  Men 52.6 (16 175) 53.8 (16 607) 54.3 (14 253) 54.7 (9442) 52.8 (2233) 49.6 (1580) 53.6 (60 290) 
  Women 53.7 (2920) 55.1 (4112) 54.4 (6256) 54.5 (7091) 50.2 (3172) 44.8 (603) 53.6 (24 154) 
 Median length of hospital stay (IQR) 
  Men 4 (3) 5 (4) 5 (5) 6 (7) 6 (9) 5 (5) 5 (5) 
  Women 5 (4) 5 (4) 6 (5) 6 (7) 7 (10) 6 (6) 6 (7) 
 In-hospital mortality 
  Men 1.5 (467) 2.6 (815) 6.2 (1625) 14.0 (2423) 24.5 (1035) 5.5 (174) 5.8 (6539) 
  Women 2.3 (126) 4.2 (313) 8.2 (944) 17.2 (2232) 28.9 (1827) 14.1 (189) 12.5 (5631) 

 
Patients with a final diagnosis is AMI (NSTEMI + STEMI) 
 Aspirin on discharge 
  Men 79.1 (48 675) 77.9 (55 083) 74.6 (57 505) 70.2 (50 171) 66.5 (17 508) 73.5 (8210) 74.5 (237 152) 
  Women 77.0 (10 690) 77.2 (16 011) 74.0 (27 850) 69.6 (38 934) 65.5 (23 562) 68.3 (4373) 77.0 (214 905) 
 Clopidogrel on discharge 
  Men 36.7 (22 566) 35.7 (25 230) 32.5 (25 031) 29.9 (21 343) 28.5 (7509) 22.9 (2557) 32.7 (104 236) 
  Women 36.0 (4992) 35.3 (7331) 32.0 (12 048) 29.4 (16 463) 25.7 (9255) 19.4 (1241) 30.1 (51 330) 
 β-Blocker on discharge 
  Men 71.9 (44 265) 68.3 (48 266) 61.3 (47 285) 53.6 (38 327) 46.0 (12 108) 60.1 (6709) 61.9 (196 960) 
  Women 64.3 (8925) 63.1 (13 084) 58.3 (21 917) 53.3 (29 843) 46.3 (16 642) 50.7 (3249) 54.9 (93 660) 
 ACE inhibitor on discharge 
  Men 70.1 (43 168) 69.6 (49 228) 66.2 (51 016) 59.4 (42 504) 49.4 (13 021) 61.7 (6886) 64.7 (205 823) 
  Women 63.4 (8792) 65.4 (13 565) 63.7 (23 979) 58.5 (32 743) 48.1 (17 286) 53.4 (3421) 58.5 (99 786) 
 Statin on discharge 
  Men 78.4 (48 261) 78.0 (55 116) 75.5 (58 154) 70.4 (50 344) 61.3 (16 131) 72.3 (8072) 74.2 (236 078) 
  Women 76.0 (10 545) 77.1 (15 986) 74.9 (28 181) 69.6 (38 920) 56.2 (20 224) 63.9 (4093) 69.2 (117 949) 
 Coronary angiography 
  Men 56.7 (34 883) 51.1 (36 119) 43.6 (33 577) 27.5 (19 654) 12.1 (3196) 34.3 (3831) 41.2 (131 260) 
  Women 53.9 (7485) 47.5 (9850) 38.7 (14 567) 22.5 (12 592) 8.8 (3153) 24.0 (1535) 28.8 (49 182) 
 Echocardiography 
  Men 48.7 (29 987) 48.9 (34 557) 49.6 (38 257) 48.6 (34 781) 41.3 (10 872) 46.4 (5182) 48.3 (153 636) 
  Women 49.2 (6823) 48.4 (10 036) 49.5 (18 642) 48.2 (26 941) 38.2 (13 728) 42.9 (2745) 46.3 (78 915) 
 Median length of hospital stay (IQR) 
  Men 5 (4) 5 (5) 6 (6) 7 (8) 7 (9) 6 (5) 6 (6) 
  Women 5 (4) 5 (5) 6 (7) 7 (9) 8 (11) 7 (8) 7 (8) 
 In-hospital mortality 
  Men 1.3 (824) 2.6 (1872) 5.6 (4506) 12.0 (8894) 19.7 (5329) 8.0 (940) 6.8 (22 365) 
  Women 1.9 (276) 3.5 (747) 6.9 (2704) 13.2 (7674) 20.6 (7700) 12.8 (861) 11.3 (19 962) 

For patients with AMI (STEMI or NSTEMI), the risk (RR, 95% CI) of being prescribed aspirin (0.54, 0.53–0.56), clopidogrel (0.59, 0.57–0.62), β-blockers (0.38, 0.37–0.39), statins (0.41, 0.40–0.42), or ACE inhibitors (0.50, 0.49–0.51) was considerably lower for those ≥85 years of age with AMI compared with those <55 year of age with AMI. The elderly were less likely to undergo coronary angiography (df = 5, P< 0.001) and echocardiography (df = 5, P< 0.001), and had greater lengths of stay (df = 5, P< 0.001) and higher in-hospital mortality rates (P< 0.001) than their younger counterparts.

Table 4

Association of age with risk of in-hospital all-cause mortality for ST-elevation myocardial infarction and non-ST-elevation myocardial infarction, by sex

Risk of in-hospital mortality Male
 
Female
 
Odds ratioa (95% CI) Odds ratiob (95% CI) Odds ratioa (95% CI) Odds ratiob (95% CI) 
STEMI 
 <55 years 1.00 1.00 1.00 1.00 
 55–64 years 1.95 (1.76–2.15) 1.97 (1.75–2.23) 1.79 (1.51–2.14) 1.89 (1.54–2.33) 
 65–74 years 4.55 (4.14–4.99) 4.41 (3.94–4.94) 3.75 (3.21–4.40) 3.80 (3.14–4.59) 
 75–84 years 11.50 (10.51–12.59) 10.62 (9.51–11.86) 8.19 (7.03–9.54) 8.29 (6.91–9.95) 
 ≥85 years 23.30 (21.09–25.74) 20.31 (17.97–22.95) 15.28 (13.10–17.83) 14.98 (12.44–18.03) 

 
NSTEMI 
 <55 years 1.00 1.00 1.00 1.00 
 55–64 years 2.00 (1.77–2.19) 2.27 (1.99–2.59) 1.78 (1.49–2.12) 1.82 (1.48–2.23) 
 65–74 years 4.17 (3.79–4.59) 4.94 (4.38–5.56) 3.81 (3.26–4.46) 4.10 (3.42–4.92) 
 75–84 years 8.94 (8.14–9.81) 10.46 (9.31–11.75) 7.53 (6.47–8.77) 8.08 (6.77–9.64) 
 ≥85 years 15.71 (14.27–17.28) 18.10 (16.05–20.41) 12.66 (10.88–14.74) 13.47 (11.27–16.08) 
Risk of in-hospital mortality Male
 
Female
 
Odds ratioa (95% CI) Odds ratiob (95% CI) Odds ratioa (95% CI) Odds ratiob (95% CI) 
STEMI 
 <55 years 1.00 1.00 1.00 1.00 
 55–64 years 1.95 (1.76–2.15) 1.97 (1.75–2.23) 1.79 (1.51–2.14) 1.89 (1.54–2.33) 
 65–74 years 4.55 (4.14–4.99) 4.41 (3.94–4.94) 3.75 (3.21–4.40) 3.80 (3.14–4.59) 
 75–84 years 11.50 (10.51–12.59) 10.62 (9.51–11.86) 8.19 (7.03–9.54) 8.29 (6.91–9.95) 
 ≥85 years 23.30 (21.09–25.74) 20.31 (17.97–22.95) 15.28 (13.10–17.83) 14.98 (12.44–18.03) 

 
NSTEMI 
 <55 years 1.00 1.00 1.00 1.00 
 55–64 years 2.00 (1.77–2.19) 2.27 (1.99–2.59) 1.78 (1.49–2.12) 1.82 (1.48–2.23) 
 65–74 years 4.17 (3.79–4.59) 4.94 (4.38–5.56) 3.81 (3.26–4.46) 4.10 (3.42–4.92) 
 75–84 years 8.94 (8.14–9.81) 10.46 (9.31–11.75) 7.53 (6.47–8.77) 8.08 (6.77–9.64) 
 ≥85 years 15.71 (14.27–17.28) 18.10 (16.05–20.41) 12.66 (10.88–14.74) 13.47 (11.27–16.08) 

aUnadjusted odds ratio for age, with hospital random intercept effects.

bAdjusted odds ratio for age, diabetes, hypertension, previous AMI, angina, previous revascularization, chronic heart failure, reperfusion (primary PCI or thrombolysis) during admission, admitting ward, admitting consultant, with hospital random intercept effects.

Risk of ST-elevation myocardial infarction and in-hospital mortality

For males and less so females, increasing age predicted a lower risk of a final diagnosis of STEMI (males ≥85 years: OR = 0.33, 95% CI: 0.32–0.34; females ≥85 years: OR = 0.62, 95% CI: 0.60–0.65). For both sexes, the risk of in-hospital mortality increased with age for STEMI (males: OR = 20.31, 95% CI: 17.97–22.95; females: OR = 14.98, 95% CI: 12.44–18.03) and NSTEMI (males: OR = 18.10, 95% CI: 16.05–20.41; females: OR = 13.47, 95% CI: 11.27–16.08). The highest risk of death occurred in males ≥85 years with STEMI (OR = 20.31, 95% CI: 17.97–22.95) (Table 4).

Year of admission and acute coronary syndrome care

For patients with AMI, the proportion with cardiogenic shock increased between 2003 and 2010: <55 years of age: 0.6% (2003) to 1.7% (2010), RR = 2.80, 95% CI: 1.79–4.32, P< 0.001; ≥85 years of age: 1.6% (2003) to 3.1% (2010), RR = 2.00, 95% CI: 1.36–2.89, P< 0.001. For patients with an admission diagnosis of STEMI, rates of primary PCI increased from 1.6% in 2003 to 60.9% in 2010 (RR = 92.41, 95% CI: 71.11–120.99, P< 0.001) for patients aged <55 years and from 0.2% to 48.5% (RR = 376.79, 95% CI: 140.18–1412.26, P< 0.001) for patients aged ≥85 years. For patients with AMI, there were significant increases in the rates of use of evidence-based pharmacological therapy rates from 2003 to 2010 (Table 5).

Table 5

Acute coronary syndrome provision of care and in-hospital mortality by year of admission

 Age group Years
 
Relative risk (95% CI) 
Provision of care 
  2003–2004 2009–2010  
Primary PCI for STEMI <55 years 3.3% 52.1% 31.57 (28.22–35.33) 
>85 years 0.5% 32.2% 82.52 (55.28–128.55) 
Aspirin on admission for AMI <55 years 86.5% 90.2% 1.43 (1.33–1.53) 
>85 years 76.6% 86.6% 1.97 (1.85–2.11) 
GP IIb–IIIa for AMI <55 years 10.2% 15.2% 1.59 (1.47–1.73) 
>85 years 2.0% 2.6% 1.31 (1.08–1.59) 
Aspirin on discharge for AMI <55 years 95.8% 82.5% 0.20 (0.19–0.22) 
>85 years 81.1% 71.6% 0.59 (0.55–0.63) 
ACE inhibitor on discharge for AMI <55 years 81.4% 76.5% 1.35 (1.27–1.42) 
>85 years 57.4% 55.9% 1.06 (1.01–1.12) 
β-Blocker on discharge for AMI <55 years 85.5% 75.3% 0.52 (0.49–0.55) 
>85 years 49.1% 56.7% 1.35 (1.29–1.43) 
Clopidogrel on discharge for AMI <55 years 56.1% 97.3% 28.48 (20.64–39.69) 
>85 years 28.1% 89.1% 81.31 (59.06–112.26) 
Statin on discharge for AMI <55 years 94.2% 82.4% 0.29 (0.26–0.31) 
>85 years 61.3% 68.6% 1.38 (1.31–1.46) 
In-hospital mortalitya 
  2003 2010  
STEMI <55 years 2.0% 1.5% 0.72 (0.39–1.25) 
>85 years 30.1% 19.4% 0.54 (0.38–0.75) 
NSTEMI <55 years 1.9% 0.9% 0.89 (0.48–1.34) 
>85 years 31.5% 20.4% 0.56 (0.42–0.73) 
 Age group Years
 
Relative risk (95% CI) 
Provision of care 
  2003–2004 2009–2010  
Primary PCI for STEMI <55 years 3.3% 52.1% 31.57 (28.22–35.33) 
>85 years 0.5% 32.2% 82.52 (55.28–128.55) 
Aspirin on admission for AMI <55 years 86.5% 90.2% 1.43 (1.33–1.53) 
>85 years 76.6% 86.6% 1.97 (1.85–2.11) 
GP IIb–IIIa for AMI <55 years 10.2% 15.2% 1.59 (1.47–1.73) 
>85 years 2.0% 2.6% 1.31 (1.08–1.59) 
Aspirin on discharge for AMI <55 years 95.8% 82.5% 0.20 (0.19–0.22) 
>85 years 81.1% 71.6% 0.59 (0.55–0.63) 
ACE inhibitor on discharge for AMI <55 years 81.4% 76.5% 1.35 (1.27–1.42) 
>85 years 57.4% 55.9% 1.06 (1.01–1.12) 
β-Blocker on discharge for AMI <55 years 85.5% 75.3% 0.52 (0.49–0.55) 
>85 years 49.1% 56.7% 1.35 (1.29–1.43) 
Clopidogrel on discharge for AMI <55 years 56.1% 97.3% 28.48 (20.64–39.69) 
>85 years 28.1% 89.1% 81.31 (59.06–112.26) 
Statin on discharge for AMI <55 years 94.2% 82.4% 0.29 (0.26–0.31) 
>85 years 61.3% 68.6% 1.38 (1.31–1.46) 
In-hospital mortalitya 
  2003 2010  
STEMI <55 years 2.0% 1.5% 0.72 (0.39–1.25) 
>85 years 30.1% 19.4% 0.54 (0.38–0.75) 
NSTEMI <55 years 1.9% 0.9% 0.89 (0.48–1.34) 
>85 years 31.5% 20.4% 0.56 (0.42–0.73) 

aUnadjusted rates

Year of admission and in-hospital mortality

For patients with STEMI, in-hospital mortality reduced from 2.0% in 2003 to 1.5% in 2010 (RR = 0.72, 95% CI: 0.39–1.25, P= 0.24) for patients aged <55 years, from 4.0% to 1.6% (RR = 0.28, 95% CI: 0.14–0.52, P< 0.001) for patients aged 55–64 years, from 19.6% to 10.6% (RR = 0.47, 95% CI: 0.36–0.60, P< 0.001) for patients aged 75–84 years, and from 30.1% to 19.4% (RR = 0.54, 95% CI: 0.38–0.75, P< 0.001) for patients aged ≥85 years (Table 5). For patients with NSTEMI, in-hospital mortality reduced from 1.9% in 2003 to 0.9% in 2010 (RR = 0.89, 95% CI: 0.48–1.34, P= 0.43) for patients aged <55 years, from 3.5% to 1.8% (RR = 0.40, 95% CI: 0.23–0.65, P= 0.001) for patients aged 55–64 years, from 19.6% to 10.6% (RR = 0.49, 95% CI: 0.39–0.61, P= 0.001) for patients aged 75–84, and from 31.5% to 20.4% (RR = 0.56, 95% CI: 0.42–0.73, P< 0.001) for patients aged ≥85 years (Table 5). These findings were upheld after multi-level adjustment (base = 2003, adjusted odds ratio for age group, diabetes, hypertension, previous AMI, angina, previous revascularization, chronic heart failure, reperfusion (primary PCI or thrombolysis) during admission, admitting ward, admitting consultant, with hospital random intercept effects): male STEMI 2010: OR = 0.60, 95% CI: 0.48–0.75; female STEMI 2010: OR = 0.55, 95% CI: 0.42–0.71; male NSTEMI: OR = 0.50, 95% CI: 0.42–0.60; female NSTEMI: OR = 0.49, 95% CI: 0.40–0.59. After adjustment for final diagnosis and hospital-level effects, there was a reduction in inpatient mortality from 2003 to 2010 across all age groups including patients ≥85 years of age: OR, 95% CI: 2004: 0.94, 0.88–1.01; 2010: 0.52, 0.44–0.61; 75–84 years of age: 2004: 0.98, 0.93–1.03; 2010: 0.52, 0.45–0.60, and patients <55 years of age: 2004: 0.94, 0.79–1.13; 2010: 0.64, 0.44–0.93 (Figure 1).

Figure 1

Odds ratios by year for in-hospital all-cause mortality, stratified by age category. 2003 = base, adjustment for final diagnosis and hospital-level random effects.

Figure 1

Odds ratios by year for in-hospital all-cause mortality, stratified by age category. 2003 = base, adjustment for final diagnosis and hospital-level random effects.

Discussion

Despite earlier research from Europe which has highlighted the need to address age-dependent inequalities in ACS quality of care,2 when compared with their younger counterparts the elderly hospitalized with an ACS continue to be disadvantaged. This is important when the elderly comprise up to a third of the ACS admissions in England and Wales. Yet, there was good evidence to suggest that all age groups including the old and very old have benefited from improvements in ACS management—for AMI, there were substantial year-on-year reductions in in-hospital mortality. Notably, the temporal improvements in the risk of in-hospital mortality were similar for males and females and for STEMI and NSTEMI.

To date, many studies have described the differential presentation, management, and outcome of elderly vs. young ACS patients.2,24–28 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. We refute findings from a recent single centre observational study which suggested that no temporal improvements in mortality rates were evident for the elderly who underwent primary PCI.29 Our research readily highlights that although age-dependent biases in quality of care exist, in England and Wales significant improvements in ACS care have occurred. From 2003 to 2010, improvements in the application of evidence-based ACS care were evident across all age groups—this is despite the increased proportion of patients presenting with cardiogenic shock. The unadjusted risk of in-hospital mortality after an ACS admission in 2010 was half that of 2003 (RR = 0.50, 95% CI: 0.45–0.54).

Several studies have suggested that improvements in hospital care for the elderly would reduce elderly ACS mortality rates.2,24–28 Our analyses using contemporary MINAP data demonstrate this association. The reductions in in-hospital mortality over time were unlikely to be due to reduction in lengths of hospital stay. For STEMI and NSTEMI, we found no significant relationships between the length of hospital stay and in-hospital mortality and there was no significant interaction between the length of hospital stay and in-hospital mortality by year of hospital admission. Furthermore, from 2003 to 2010, 30-day mortality rates fell for STEMI (RR = 0.43, 95% CI: 0.34–0.54, P< 0.001) and NSTEMI (RR = 0.66, 95% CI: 0.55–0.78, P< 0.001) suggesting that the reduction in in-hospital mortality rates was unlikely to be related to hasty (or inappropriate) discharge from hospital care. It is possible, however, that some of the improvements in NSTEMI mortality rates related to a lower risk profile in later years: the median (IQR) troponin concentration for NSTEMI decreased from 0.57 (2.80) in 2003 to 0.48 (2.56), P< 0.001.

While the adjusted risk of the temporal decline in in-hospital mortality for STEMI and NSTEMI <55 years of age were statistically significant, we found there was only a non-significant trend in the decline of the absolute risk (20% and 47%, respectively) in this group. In 2003, mortality rates in the young were already low (2.0%) and it is possible that in-hospital mortality rates lower than 1.6% (2010) are now reaching a ‘plateau of achievable care’,30,31 and that a statistically significant association would require much greater numbers of patients or evaluation of survival beyond the hospital stay.

Overall our findings are in keeping with international advances in the provision of evidence-based acute cardiac care. They herald the accomplishment in England and Wales of the NSF for Coronary Heart disease (2000–2010).15 This was a nationwide implementation strategy of changes to the delivery of care for patients with coronary heart disease and encouraged the adoption of the translation of contemporary evidence into best practice.20,32 Nevertheless, our research continues to support a notion of age-dependent inequality in ACS care and, moreover, highlights gaps in key aspects of the management of elderly patients with ACS who benefit equally as much as their younger counterparts from an early invasive strategy.28,33,34

This study provides evidence for opportunities for improvements in the quality of clinical care. For example, despite high frequencies of previous AMI in the very elderly, they had previously less often undergone revascularization when advanced age alone must not be considered a contraindication to performing coronary angiography and PCI.34 Overall, rates of emergency reperfusion (primary PCI and thrombolysis) for STEMI in those aged <55 years were nearly three times higher than those aged ≥85 years. For those with a final diagnosis of AMI, older patients were less likely to be discharged on aspirin, clopidogrel, β-blockers, ACE inhibitors, and statins. In light of our evidence for increased risk of early mortality and greater lengths of hospital stay, the application of evidence-base ACS therapies to appropriate patients regardless of age may further reduce overall cost and improve early outcomes.2

The causes for discrepancies in quality care for the elderly are multifactorial. In part, the shortfalls in treatment may be due to the lack of appropriate specialist care and inappropriate placement within the hospital.35 Although the MINAP database includes data relating to the indication, contraindication, refusal of treatments (all taken into account in the analyses), we were unable to evaluate the appropriateness of ACS management.36 Reductions in risk of inpatient death may be related to improved primary37 and secondary prevention;38 however, we specifically considered in-hospital mortality (rather than longer term survival) because this more clearly reflects acute care associated with the index admission. Nonetheless, improvements in mortality are associated with the application of evidence-based medicine,38 and it is likely that the implementation of strategic networks of care (such as the national primary PCI service in England and Wales20) has contributed to the greater application of ACS treatments and hence better outcomes.39

Not withstanding age-dependent inequalities in care, the elderly are more likely to present differently and less likely to have the same diagnosis on discharge from hospital as that which they were given on admission. In our study, the risk of a change in diagnosis from that on admission to a different one on discharge in patients ≥85 years of age was over 10% greater than that for patients <55 years of age: RR, 95% CI 1.12, 1.09–1.16. Multi-level adjustment made little difference to the risk of in-hospital mortality and suggests that the ‘diagnosis’ per se is a stronger predictor of outcome than the covariates modelled. As such, mechanisms to improve the early and accurate diagnosis of specific ACS subgroups in the elderly are needed so that timely risk-evaluated ACS interventions may be implemented. It is plausible that physicians already know that the likelihood of an elderly patient presenting with STEMI is much lower than that of a younger patient and that this influences their perception of a diagnosis of STEMI in an older patient. Finally, age-dependent inequalities in treatments may be the legacy of a risk-adverse strategy to ACS care4 through lack of accurate estimation of ACS risk.40

Limitations

MINAP does not collect data on all patients in England and Wales, and it is possible that patients entered into the MINAP database differ from those not recorded. We noted that data missingness for age was 4.3% and for final diagnosis 3.2%. Although this may introduce systematic bias, we have previously noted that while being statistically significant the inclusion of missing data does not alter regional standardized mortality ratios.41 As with all observational data, the modelling of diagnosis, in-hospital mortality, and effect of year considered hospital-level and patient-specific influences and the use of alternative covariates may change the effect sizes demonstrated. Finally, this research reveals important associations but cannot prove causation.

Conclusion

The elderly comprise a substantial proportion of ACS admissions. They have a different risk factor and ACS diagnosis profile to younger patients. Biases in elderly ACS care remain and the elderly have significantly longer hospital lengths of stay and higher in-hospital mortality rates. Despite this, improvements in the application of evidence-based ACS care were evident across all age groups from 2003 to 2010. There were significant year-on-year reductions in in-hospital mortality equally across all age groups, both sexes, and for STEMI and NSTEMI.

Ethical approval

The National Institute for Cardiovascular Research (NICOR) which includes the Myocardial Ischaemia National Audit Project (MINAP) (Ref: NIGB: ECC 1-06 (d)/2011) has support under section 251 of the National Health Service (NHS) Act 2006. On seeking advice from Leeds (West) Research Ethics Committee, formal ethical approval was not required under NHS research governance arrangements for the project.

Funding

MINAP is funded by the Health Quality Improvement Partnership (HQIP). This study was funded by the British Heart Foundation. C.P.G. is funded by the National Institute for Health Research as a Clinician Scientist and Honorary Consultant Cardiologist

Conflicts of interest: none declared.

Acknowledgements

All of the authors gratefully acknowledge funding from the British Heart Foundation PG/07/057/23215. C.P.G. is funded through the National Institute for Health Research (NIHR). The extract from the MINAP database was provided through the MINAP Academic Group. We acknowledge all the hospitals in England and Wales for their contribution of data to MINAP. There are no competing interests and the authors have nothing to declare.

References

1
Avezum
A
Makdisse
M
Spencer
F
Gore
JM
Fox
KA
Montalescot
G
Eagle
KA
White
K
Mehta
RH
Knobel
E
Collet
JP
Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE)
Am Heart J
 , 
2005
, vol. 
149
 (pg. 
67
-
73
)
2
Rosengren
A
Wallentin
L
Simoons
M
Gitt
AK
Behar
S
Battler
A
Hasdai
D
Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey
Eur Heart J
 , 
2006
, vol. 
27
 (pg. 
789
-
795
)
3
Collinson
J
Bakhai
A
Flather
MD
Fox
KA
The management and investigation of elderly patients with acute coronary syndromes without ST elevation: an evidence-based approach? Results of the Prospective Registry of Acute Ischaemic Syndromes in the United Kingdom (PRAIS-UK)
Age Ageing
 , 
2005
, vol. 
34
 (pg. 
61
-
66
)
4
Fox
KA
Anderson
FA
Jr
Dabbous
OH
Steg
PG
Lopez-Sendon
J
Van de Werf
F
Budaj
A
Gurfinkel
EP
Goodman
SG
Brieger
D
Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE)
Heart
 , 
2007
, vol. 
93
 (pg. 
177
-
182
)
5
Gabriel
SP
Iung
B
Feldman
LJ
Maggioni
AP
Keil
U
Deckers
J
Cokkinos
D
Fox
KA
Determinants of use and outcomes of invasive coronary procedures in acute coronary syndromes: results from ENACT
Eur Heart J
 , 
2003
, vol. 
24
 (pg. 
613
-
622
)
6
Tran
CT
Laupacis
A
Mamdani
MM
Tu
JV
Effect of age on the use of evidence-based therapies for acute myocardial infarction
Am Heart J
 , 
2004
, vol. 
148
 (pg. 
834
-
841
)
7
Hasdai
D
Holmes
DR
Jr
Criger
DA
Topol
EJ
Califf
RM
Harrington
RA
Age and outcome after acute coronary syndromes without persistent ST-segment elevation
Am Heart J
 , 
2000
, vol. 
139
 (pg. 
858
-
866
)
8
Jernberg
T
Johanson
P
Held
C
Svennblad
B
Lindback
J
Wallentin
L
Association between adoption of evidence-based treatment and survival for patients with ST-elevation myocardial infarction
JAMA
 , 
2011
, vol. 
305
 (pg. 
1677
-
1684
)
9
Fox
KA
Steg
PG
Eagle
KA
Goodman
SG
Anderson
FA
Jr
Granger
CB
Flather
MD
Budaj
A
Quill
A
Gore
JM
Decline in rates of death and heart failure in acute coronary syndromes, 1999–2006
JAMA
 , 
2007
, vol. 
297
 (pg. 
1892
-
1900
)
10
Yan
AT
Yan
RT
Tan
M
Huynh
T
Soghrati
K
Brunner
LJ
DeYoung
P
Fitchett
DH
Langer
A
Goodman
SG
Optimal medical therapy at discharge in patients with acute coronary syndromes: temporal changes, characteristics, and 1-year outcome
Am Heart J
 , 
2007
, vol. 
154
 (pg. 
1108
-
1115
)
11
Peterson
ED
Shah
BR
Parsons
L
Pollack
J
French
WJ
Canto
JG
Gibson
CM
Rogers
WJ
Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006
Am Heart J
 , 
2008
, vol. 
156
 (pg. 
1045
-
1055
)
12
Thygesen
K
Alpert
JS
White
HD
Jaffe
AS
Apple
FS
Galvani
M
Katus
HA
Newby
LK
Ravkilde
J
Chaitman
B
Clemmensen
PM
Dellborg
M
Hod
H
Porela
P
Underwood
R
Bax
JJ
Beller
GA
Bonow
R
Van der Wall
EE
Bassand
JP
Wijns
W
Ferguson
TB
Steg
PG
Uretsky
BF
Williams
DO
Armstrong
PW
Antman
EM
Fox
KA
Hamm
CW
Ohman
EM
Simoons
ML
Poole-Wilson
PA
Gurfinkel
EP
Lopez-Sendon
JL
Pais
P
Mendis
S
Zhu
JR
Wallentin
LC
Fernandez-Aviles
F
Fox
KM
Parkhomenko
AN
Priori
SG
Tendera
M
Voipio-Pulkki
LM
Vahanian
A
Camm
AJ
De Caterina
R
Dean
V
Dickstein
K
Filippatos
G
Funck-Brentano
C
Hellemans
I
Kristensen
SD
McGregor
K
Sechtem
U
Silber
S
Tendera
M
Widimsky
P
Zamorano
JL
Morais
J
Brener
S
Harrington
R
Morrow
D
Lim
M
Martinez-Rios
MA
Steinhubl
S
Levine
GN
Gibler
WB
Goff
D
Tubaro
M
Dudek
D
Al Attar
N
Universal definition of myocardial infarction
Circulation
 , 
2007
, vol. 
116
 (pg. 
2634
-
2653
)
13
Alexander
KP
Newby
LK
Armstrong
PW
Cannon
CP
Gibler
WB
Rich
MW
Van de Werf
F
White
HD
Weaver
WD
Naylor
MD
Gore
JM
Krumholz
HM
Ohman
EM
Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology
Circulation
 , 
2007
, vol. 
115
 (pg. 
2570
-
2589
)
14
Alexander
KP
Newby
LK
Cannon
CP
Armstrong
PW
Gibler
WB
Rich
MW
Van de Werf
F
White
HD
Weaver
WD
Naylor
MD
Gore
JM
Krumholz
HM
Ohman
EM
Acute coronary care in the elderly, part I: non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology
Circulation
 , 
2007
, vol. 
115
 (pg. 
2549
-
2569
)
15
Department of Health
National Service Framework for Coronary Heart Disease
 , 
2000
London
 
The Stationary Office
17
Birkhead
J
Walker
L
National audit of myocardial infarction (MINAP): a project in evolution
Hosp Med
 , 
2004
, vol. 
65
 (pg. 
452
-
453
)
18
Birkhead
JS
Responding to the requirements of the national service framework for coronary disease: a core data set for myocardial infarction
Heart
 , 
2000
, vol. 
84
 (pg. 
116
-
117
)
19
Herrett
E
Smeeth
L
Walker
L
Weston
C
The Myocardial Ischaemia National Audit Project (MINAP)
Heart
 , 
2010
, vol. 
96
 (pg. 
1264
-
1267
)
20
West
RM
Cattle
BA
Bouyssie
M
Squire
I
de Belder
M
Fox
KA
Boyle
R
McLenachan
JM
Batin
PD
Greenwood
DC
Gale
CP
Impact of hospital proportion and volume on primary percutaneous coronary intervention performance in England and Wales
Eur Heart J
 , 
2011
, vol. 
32
 (pg. 
706
-
711
)
21
Rickards
A
Cunningham
D
From quantity to quality: the central cardiac audit database project
Heart
 , 
1999
, vol. 
82
 
Suppl 2
(pg. 
18
-
22
)
22
Prepared on behalf of the MINAP Steering Group
How the NHS manages heart attacks. Tenth Public Report 2011
2009
London
National Institute for Clinical Outcomes Research
23
Myocardial infarction redefined – a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction
Eur Heart J
 , 
2000
, vol. 
21
 (pg. 
1502
-
1513
The Joint European Society of Cardiology/American College of Cardiology Committee
24
Halon
DA
Adawi
S
Dobrecky-Mery
I
Lewis
BS
Importance of increasing age on the presentation and outcome of acute coronary syndromes in elderly patients
J Am Coll Cardiol
 , 
2004
, vol. 
43
 (pg. 
346
-
352
)
25
Goldberg
RJ
McCormick
D
Gurwitz
JH
Yarzebski
J
Lessard
D
Gore
JM
Age-related trends in short- and long-term survival after acute myocardial infarction: a 20-year population-based perspective (1975–1995)
Am J Cardiol
 , 
1998
, vol. 
82
 (pg. 
1311
-
1317
)
26
Goldberg
RJ
Gore
JM
Gurwitz
JH
Alpert
JS
Brady
P
Strohsnitter
W
Chen
ZY
Dalen
JE
The impact of age on the incidence and prognosis of initial acute myocardial infarction: the Worcester Heart Attack Study
Am Heart J
 , 
1989
, vol. 
117
 (pg. 
543
-
549
)
27
Yan
RT
Yan
AT
Tan
M
Chow
CM
Fitchett
DH
Ervin
FL
Cha
JYM
Langer
A
Goodman
SG
Age-related differences in the management and outcome of patients with acute coronary syndromes
Am Heart J
 , 
2006
, vol. 
151
 (pg. 
352
-
359
)
28
Devlin
G
Gore
JM
Elliott
J
Wijesinghe
N
Eagle
KA
Avezum
A
Huang
W
Brieger
D
Management and 6-month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: the Global Registry of Acute Coronary Events
Eur Heart J
 , 
2008
, vol. 
29
 (pg. 
1275
-
1282
)
29
Claessen
BE
Kikkert
WJ
Engstrom
AE
Hoebers
LP
Damman
P
Vis
MM
Koch
KT
Baan
J
Jr
Meuwissen
M
van der Schaaf
RJ
de Winter
RJ
Tijssen
JG
Piek
JJ
Henriques
JP
Primary percutaneous coronary intervention for ST elevation myocardial infarction in octogenarians: trends and outcomes
Heart
 , 
2010
, vol. 
96
 (pg. 
843
-
847
)
30
O'Flaherty
M
Ford
E
Allender
S
Scarborough
P
Capewell
S
Coronary heart disease trends in England and Wales from 1984 to 2004: concealed levelling of mortality rates among young adults
Heart
 , 
2008
, vol. 
94
 (pg. 
178
-
181
)
31
Ford
ES
Capewell
S
Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: concealed leveling of mortality rates
J Am Coll Cardiol
 , 
2007
, vol. 
50
 (pg. 
2128
-
2132
)
32
Birkhead
JS
Walker
L
Pearson
M
Weston
C
Cunningham
AD
Rickards
AF
Improving care for patients with acute coronary syndromes: initial results from the National Audit of Myocardial Infarction Project (MINAP)
Heart
 , 
2004
, vol. 
90
 (pg. 
1004
-
1009
)
33
Birkhead
JS
Weston
CF
Chen
R
Determinants and outcomes of coronary angiography after non-ST-segment elevation myocardial infarction. A cohort study of the Myocardial Ischaemia National Audit Project (MINAP)
Heart
 , 
2009
, vol. 
95
 (pg. 
1593
-
1599
)
34
From
AM
Rihal
CS
Lennon
RJ
Holmes
DR
Jr
Prasad
A
Temporal trends and improved outcomes of percutaneous coronary revascularization in nonagenarians
JACC: Cardiovasc Interv
 , 
2008
, vol. 
1
 (pg. 
692
-
698
)
35
Birkhead
JS
Weston
C
Lowe
D
Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004–5: observational study
BMJ
 , 
2006
, vol. 
332
 (pg. 
1306
-
1311
)
36
Hemingway
H
Crook
AM
Feder
G
Banerjee
S
Dawson
JR
Magee
P
Philpott
S
Sanders
J
Wood
A
Timmis
AD
Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization
N Engl J Med
 , 
2001
, vol. 
344
 (pg. 
645
-
654
)
37
Unal
B
Critchley
JA
Capewell
S
Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000
Circulation
 , 
2004
, vol. 
109
 (pg. 
1101
-
1107
)
38
Fox
KAA
Steg
PG
Eagle
KA
Goodman
SG
Anderson
FA
Granger
CB
Flather
MD
Budaj
A
Quill
A
Gore
JM
for the GRACE Investigators
Decline in rates of death and heart failure in acute coronary syndromes, 1999–2006
JAMA: J Am Med Assoc
 , 
2007
, vol. 
297
 (pg. 
1892
-
1900
)
39
Fox
KA
Huber
K
A European perspective on improving acute systems of care in STEMI: we know what to do, but how can we do it?
Nat Clin Pract Cardiovasc Med
 , 
2008
, vol. 
5
 (pg. 
708
-
714
)
40
Bagnall
AJ
Goodman
SG
Fox
KAA
Yan
RT
Gore
JM
Cheema
AN
Huynh
T
Chauret
D
Fitchett
DH
Langer
A
Yan
AT
Influence of age on use of cardiac catheterization and associated outcomes in patients with non-ST-elevation acute coronary syndromes
Am J Cardiol
 , 
2009
, vol. 
103
 (pg. 
1530
-
1536
)
41
Gale
CP
Cattle
BA
Moore
J
Dawe
H
Greenwood
DC
West
RM
Impact of missing data on standardised mortality ratios for acute myocardial infarction: evidence from the Myocardial Ischaemia National Audit Project (MINAP) 2004–7
Heart
  
2011. Published online ahead of print 28 February 2011

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