Investigators: Michael Shechter Michael.Shechter@sheba.health.gov.il Roi Rubinshtein rubin2r@gmail.com
Data set includes women from ACSIS 2000-2016
To evaluate the treatment and clinical outcome in women with ACS \(\ge\) 80 years compared with those aged \(\lt\) 80 years over the 2000 to 2016 period. The second objective was to evaluate trends in treatment and mortality rates of ACS women aged\(\ge\) 80 years over the same period.
The main outcomes are: 30-day mortality and 1-year mortality.
The main comparison is between ACS women \(\lt\) 80 (n=2660)
and ACS women \(\ge\) 80 (n=858).
The second comparison is for women aged 80+ in the 2000-2006 survey years(n=450),
compared with the survey years 2008-2016 (n=408).
Patients characteristics was recorded on table-1 and table-2 for the two study groups.
The two groups were tested with chi-square for categorical variables and with t-test or Mannb Whitneyb Wilcoxon test as appropriate for normal/nonnormal distributed continues variables.
Survival analysis between the groups was performed using the Kaplan Meier curves followed by the Log Rank test.
In order to explore the relationship between survival and study groups and other explanatory covariates, Cox models were performed.
| <80 | 80+ | P value | |
|---|---|---|---|
| n | 2660 | 858 | |
| Baseline characteristics | |||
| Age, years (mean B1 SD) | 65.59 (9.94) | 84.94 (4.38) | <0.001 |
| Dyslipidemia | 1847 (69.6) | 514 (60.5) | <0.001 |
| Hypertension | 1846 (69.5) | 722 (84.4) | <0.001 |
| Current smokers | 607 (23.0) | 34 ( 4.0) | <0.001 |
| Diabetes mellitus | 1221 (46.1) | 295 (34.6) | <0.001 |
| Family history of CAD | 566 (22.7) | 52 ( 6.9) | <0.001 |
| BMI (kg/m2), (mean B1 SD) | 28.74 (9.44) | 26.67 (4.90) | <0.001 |
| Prior MI | 629 (23.7) | 265 (31.0) | <0.001 |
| Prior CABG | 199 ( 7.5) | 64 ( 7.5) | 1.000 |
| Prior PCI | 564 (21.2) | 159 (18.6) | 0.109 |
| Chronic renal failure | 243 ( 9.2) | 161 (18.9) | <0.001 |
| PVD | 191 ( 7.2) | 65 ( 7.6) | 0.739 |
| s/p CVA/TIA | 238 ( 9.0) | 128 (15.0) | <0.001 |
| History of CHF | 220 ( 8.3) | 139 (16.3) | <0.001 |
| Prior medications | |||
| Aspirin | 1079 (47.7) | 419 (55.2) | <0.001 |
| Clopidogrel | 181 ( 8.0) | 67 ( 8.8) | 0.520 |
| ACE-I/ARB | 718 (27.0) | 308 (35.9) | <0.001 |
| Beta blockers | 933 (41.5) | 385 (51.4) | <0.001 |
| Statins | 1146 (51.8) | 351 (47.5) | 0.048 |
| CCB | 574 (25.6) | 283 (38.0) | <0.001 |
| Nitrates | 276 (12.3) | 164 (22.2) | <0.001 |
| Aldosterone receptor antagonist | 23 ( 2.6) | 10 ( 3.4) | 0.631 |
| Hypoglycemic agents | 688 (30.1) | 155 (20.3) | <0.001 |
| Diuretics | 443 (23.4) | 231 (36.6) | <0.001 |
| Means of arrival to hospital and time to treatment | |||
| Mobile ICCU | 876 (33.4) | 373 (43.9) | <0.001 |
| Regular ambulance | 389 (14.8) | 157 (18.5) | 0.013 |
| Private car | 1181 (45.1) | 258 (30.4) | <0.001 |
| Time from symptoms onset to ER (median,IQR) (min) | 195.00 [95.00, 590.00] | 201.00 [100.00, 464.25] | 0.952 |
| Time from ER to 1st ward (median,IQR) (min) | 113.00 [54.00, 203.00] | 124.00 [60.00, 220.00] | 0.015 |
| Door to balloon time (median,IQR) (min) | 67.00 [36.00, 130.50] | 83.00 [45.00, 143.00] | 0.052 |
| Killip class on admission | |||
| I | 2122 (80.8) | 543 (64.2) | <0.001 |
| II | 290 (11.0) | 163 (19.3) | <0.001 |
| III | 168 ( 6.4) | 115 (13.6) | <0.001 |
| IV | 46 ( 1.8) | 25 ( 3.0) | 0.044 |
| LVEF<50% rates | |||
| LVEF<50% | 444 (47.9) | 174 (58.2) | 0.003 |
| Post admission therapy | |||
| Reperfusion therapy | |||
| STEMI | 1111 (41.8) | 370 (43.1) | 0.520 |
| Reperfusion therapy in STEMI | 713 (26.8) | 175 (20.4) | <0.001 |
| Thrombolysis | 193 (27.1) | 42 (24.0) | 0.466 |
| Angio without PCI/urgent CABG | 11 ( 0.5) | 5 ( 0.7) | 0.740 |
| Primary PCI in all patients | 506 (71.0) | 128 (73.1) | 0.633 |
| Primary PCI in STEMI | 487 (43.8) | 122 (33.0) | <0.001 |
| Any PCI in CCU- STEMI | 771 (69.4) | 175 (47.3) | <0.001 |
| Any PCI in CCU- all patients | 1508 (56.7) | 358 (41.7) | <0.001 |
| Use of IIb/IIIa antagonists | 272 (33.8) | 39 (17.2) | <0.001 |
| In-hospital therapy | |||
| Aspirin | 2497 (94.1) | 785 (91.7) | 0.018 |
| Clopidogrel | 1671 (63.3) | 501 (58.7) | 0.020 |
| Warfarin/oral anticoagulation | 161 ( 6.1) | 68 ( 8.0) | 0.063 |
| UF heparin | 1196 (45.4) | 359 (42.3) | 0.121 |
| LMW heparin | 1277 (48.4) | 414 (48.8) | 0.903 |
| ACE-I/ARB | 1309 (49.2) | 404 (47.1) | 0.297 |
| Beta blockers | 2097 (79.1) | 600 (70.3) | <0.001 |
| Diuretics | 874 (33.7) | 467 (55.9) | <0.001 |
| Statins | 2062 (79.2) | 605 (72.6) | <0.001 |
| CCB | 445 (19.8) | 181 (25.3) | 0.002 |
| Nitrates | 839 (37.3) | 298 (41.9) | 0.031 |
| Therapy at 30-day follow-up | |||
| Hypoglycemic agents | 508 (19.3) | 100 (11.7) | <0.001 |
| Aspirin | 925 (92.8) | 270 (87.7) | 0.007 |
| Clopidogrel | 581 (61.7) | 212 (71.4) | 0.003 |
| Statins | 917 (93.2) | 272 (90.1) | 0.094 |
| ACE-I/ARB | 730 (27.4) | 234 (27.3) | 0.957 |
| Beta blockers | 793 (82.1) | 233 (77.9) | 0.128 |
| Referral to rehabilitation program | 572 (23.2) | 100 (14.0) | <0.001 |
| Participating in a rehabilitation program | 169 ( 6.9) | 21 ( 3.0) | <0.001 |
| Clinical outcomes | |||
| In-hospital complictions | |||
| Killip 3 | 237 ( 8.9) | 141 (16.5) | <0.001 |
| Killip 4 | 109 ( 4.1) | 69 ( 8.1) | <0.001 |
| Re MI | 36 ( 1.4) | 16 ( 1.9) | 0.356 |
| Post MI angina | 163 ( 6.2) | 60 ( 7.1) | 0.403 |
| Stent thrombosis | 17 ( 1.1) | 5 ( 1.0) | 0.941 |
| Ischemic stroke | 12 (75.0) | 13 (81.2) | 1.000 |
| Free wall rupture | 10 ( 0.4) | 17 ( 2.0) | <0.001 |
| High degreeAV block | 73 ( 2.8) | 45 ( 5.3) | 0.001 |
| TIA/CVA | 21 ( 0.8) | 20 ( 2.3) | 0.001 |
| Acute renal failure | 159 ( 6.0) | 125 (14.7) | <0.001 |
| Major bleeding | 49 ( 1.8) | 30 ( 3.5) | 0.006 |
| Death rates | |||
| In-hospital death | 121 ( 4.5) | 112 (13.1) | <0.001 |
| 7-day mortality | 83 ( 3.1) | 82 ( 9.6) | <0.001 |
| 30-day mortality | 145 ( 5.5) | 134 (15.6) | <0.001 |
| 1-year mortality | 262 ( 9.9) | 241 (28.3) | <0.001 |
## Call: survfit(formula = Surv(time1y, status1y) ~ group, data = na.omit(dat[,
## c("time1y", "status1y", "group")]))
##
## group=0
## time n.risk n.event survival std.err lower 95% CI upper 95% CI
## 0 2639 0 1.000 0.00000 1.000 1.000
## 2 2463 174 0.934 0.00483 0.925 0.944
## 4 2439 23 0.925 0.00512 0.915 0.935
## 6 2411 28 0.915 0.00544 0.904 0.925
## 8 2401 9 0.911 0.00554 0.900 0.922
## 10 2390 11 0.907 0.00565 0.896 0.918
## 12 2373 17 0.901 0.00583 0.889 0.912
##
## group=1
## time n.risk n.event survival std.err lower 95% CI upper 95% CI
## 0 853 0 1.000 0.0000 1.000 1.000
## 2 686 162 0.810 0.0134 0.784 0.837
## 4 664 22 0.784 0.0141 0.757 0.812
## 6 641 23 0.757 0.0147 0.729 0.786
## 8 625 16 0.738 0.0151 0.709 0.768
## 10 618 7 0.730 0.0152 0.700 0.760
## 12 607 11 0.717 0.0155 0.687 0.748Presented models include:
| Dependent variable: | ||
| 1-Year Mortality | ||
| b b b - Model 0 b b b - | b b b - Model 1 b b b - | |
| Age group: 80+ | 3.18*** (2.67, 3.79) | 2.23*** (1.84, 2.71) |
| p = 0.00 | p = 0.00 | |
| Period: 2008-2016 | 0.92 (0.76, 1.13) | |
| p = 0.44 | ||
| Dyslipidemia=YES | 0.54*** (0.45, 0.66) | |
| p = 0.00 | ||
| Hypertension=YES | 1.00 (0.80, 1.26) | |
| p = 1.00 | ||
| Diabetes=YES | 1.47*** (1.21, 1.78) | |
| p = 0.0001 | ||
| Prior MI=YES | 1.34* (1.07, 1.67) | |
| p = 0.02 | ||
| PVD=YES | 1.74*** (1.32, 2.31) | |
| p = 0.0002 | ||
| Prior CABG=YES | 0.85 (0.60, 1.21) | |
| p = 0.38 | ||
| Prior PCI=YES | 0.60*** (0.45, 0.80) | |
| p = 0.0005 | ||
| History of CHF=YES | 1.11 (0.87, 1.43) | |
| p = 0.41 | ||
| s/p CVA/TIA=YES | 1.16 (0.90, 1.49) | |
| p = 0.26 | ||
| Prior AP 24 hours=YES | 0.77* (0.63, 0.94) | |
| p = 0.02 | ||
| Prior Chronic Renal Failure=YES | 1.41** (1.11, 1.79) | |
| p = 0.005 | ||
| Current smokers=YES | 0.73 (0.53, 1.01) | |
| p = 0.06 | ||
| Adm. killip class >1 | 2.84*** (2.33, 3.44) | |
| p = 0.00 | ||
| Observations | 3,492 | 3,372 |
| Note: | p<0.05; p<0.01; p<0.001 | |
| Dependent variable: | ||
| 30-Day Mortality | ||
| b b b - Model 0 b b b - | b b b - Model 1 b b b - | |
| Age group: 80+ | 3.03*** (2.40, 3.83) | 1.94*** (1.50, 2.52) |
| p = 0.00 | p = 0.0000 | |
| Period: 2008-2016 | 1.10 (0.84, 1.43) | |
| p = 0.49 | ||
| Dyslipidemia=YES | 0.48*** (0.37, 0.62) | |
| p = 0.0000 | ||
| Hypertension=YES | 0.89 (0.67, 1.20) | |
| p = 0.46 | ||
| Diabetes=YES | 1.24 (0.96, 1.60) | |
| p = 0.11 | ||
| Prior MI=YES | 1.06 (0.77, 1.46) | |
| p = 0.72 | ||
| PVD=YES | 1.75** (1.18, 2.60) | |
| p = 0.01 | ||
| Prior CABG=YES | 0.71 (0.40, 1.24) | |
| p = 0.23 | ||
| Prior PCI=YES | 0.44*** (0.27, 0.70) | |
| p = 0.0005 | ||
| History of CHF=YES | 1.16 (0.82, 1.63) | |
| p = 0.41 | ||
| s/p CVA/TIA=YES | 1.24 (0.89, 1.74) | |
| p = 0.21 | ||
| Prior AP 24 hours=YES | 0.96 (0.73, 1.25) | |
| p = 0.76 | ||
| Prior Chronic Renal Failure=YES | 1.05 (0.75, 1.48) | |
| p = 0.76 | ||
| Current smokers=YES | 0.61* (0.39, 0.95) | |
| p = 0.03 | ||
| Adm. killip class >1 | 3.61*** (2.77, 4.69) | |
| p = 0.00 | ||
| Observations | 3,508 | 3,388 |
| Note: | p<0.05; p<0.01; p<0.001 | |
| 2000-2006 | 2008-2016 | P value | |
|---|---|---|---|
| n | 450 | 408 | |
| Baseline characteristics | |||
| Age, years (mean B1 SD) | 84.53 (4.21) | 85.38 (4.52) | 0.005 |
| Dyslipidemia | 204 (45.7) | 310 (76.7) | <0.001 |
| Hypertension | 359 (79.8) | 363 (89.6) | <0.001 |
| Current smokers | 16 ( 3.6) | 18 ( 4.4) | 0.689 |
| Diabetes mellitus | 141 (31.5) | 154 (38.1) | 0.050 |
| Family history of CAD | 21 ( 4.8) | 31 ( 9.7) | 0.013 |
| BMI (kg/m2), (mean B1 SD) | 26.59 (4.88) | 26.75 (4.93) | 0.675 |
| Prior MI | 129 (28.7) | 136 (33.5) | 0.152 |
| Prior CABG | 28 ( 6.2) | 36 ( 8.8) | 0.190 |
| Prior PCI | 57 (12.7) | 102 (25.1) | <0.001 |
| Chronic renal failure | 77 (17.2) | 84 (20.7) | 0.223 |
| PVD | 39 ( 8.7) | 26 ( 6.4) | 0.251 |
| s/p CVA/TIA | 70 (15.7) | 58 (14.3) | 0.631 |
| History of CHF | 71 (15.8) | 68 (16.7) | 0.805 |
| Prior medications | |||
| Aspirin | 198 (55.3) | 221 (55.1) | 1.000 |
| Clopidogrel | 14 ( 3.9) | 53 (13.2) | <0.001 |
| ACE-I/ARB | 67 (14.9) | 241 (59.1) | <0.001 |
| Beta blockers | 167 (46.5) | 218 (55.9) | 0.013 |
| Statins | 128 (35.7) | 223 (58.7) | <0.001 |
| CCB | 123 (34.4) | 160 (41.3) | 0.059 |
| Nitrates | 104 (29.1) | 60 (15.8) | <0.001 |
| Aldosterone receptor antagonist | 0 ( NaN) | 10 ( 3.4) | NaN |
| Hypoglycemic agents | 66 (18.4) | 89 (21.9) | 0.261 |
| Diuretics | 99 (40.4) | 132 (34.1) | 0.129 |
| Means of arrival to hospital and time to treatment | |||
| Mobile ICCU | 193 (43.8) | 180 (44.1) | 0.972 |
| Regular ambulance | 84 (19.0) | 73 (17.9) | 0.730 |
| Private car | 132 (29.9) | 126 (30.9) | 0.821 |
| Time from symptoms onset to ER (median,IQR) (min) | 202.50 [105.00, 505.25] | 199.50 [96.75, 426.00] | 0.278 |
| Time from ER to 1st ward (median,IQR) (min) | 120.00 [62.00, 195.00] | 132.00 [59.00, 239.50] | 0.407 |
| Door to balloon time (median,IQR) (min) | 92.50 [49.75, 146.00] | 79.00 [45.00, 130.00] | 0.453 |
| Killip class on admission | |||
| >1 | 192 (43.0) | 111 (27.8) | <0.001 |
| >2 | 90 (20.1) | 50 (12.5) | 0.004 |
| LVEF<50% rates | |||
| LVEF<50% | 41 (60.3) | 133 (57.6) | 0.795 |
| Post admission therapy | |||
| Reperfusion therapy | |||
| STEMI | 210 (46.7) | 160 (39.2) | 0.033 |
| Reperfusion therapy in STEMI | 87 (19.3) | 88 (21.6) | 0.467 |
| Thrombolysis | 40 (46.0) | 2 ( 2.3) | <0.001 |
| Angio without PCI/urgent CABG | 0 ( 0.0) | 5 ( 1.9) | 0.014 |
| Primary PCI in all patients | 47 (54.0) | 81 (92.0) | <0.001 |
| Primary PCI in STEMI | 43 (20.5) | 79 (49.4) | <0.001 |
| Any PCI in CCU- STEMI | 69 (32.9) | 106 (66.2) | <0.001 |
| Any PCI in CCU- all patients | 128 (28.4) | 230 (56.4) | <0.001 |
| Use of IIb/IIIa antagonists | 15 (10.6) | 24 (27.9) | 0.002 |
| In-hospital therapy | |||
| Aspirin | 418 (93.3) | 367 (90.0) | 0.098 |
| Clopidogrel | 177 (39.7) | 324 (79.6) | <0.001 |
| Warfarin/oral anticoagulation | 30 ( 6.8) | 38 ( 9.3) | 0.211 |
| UF heparin | 201 (45.4) | 158 (38.9) | 0.067 |
| LMW heparin | 237 (53.6) | 177 (43.5) | 0.004 |
| ACE-I/ARB | 111 (24.7) | 293 (71.8) | <0.001 |
| Beta blockers | 299 (67.2) | 301 (73.8) | 0.043 |
| Diuretics | 268 (60.1) | 199 (51.0) | 0.010 |
| Statins | 248 (55.9) | 357 (91.8) | <0.001 |
| Digoxin | 25 ( 5.6) | 8 ( 2.1) | 0.017 |
| Nitrates | 179 (54.4) | 119 (31.2) | <0.001 |
| Hypoglycemic agents | 40 ( 9.0) | 60 (14.7) | 0.012 |
| Therapy at 30-day follow-up | |||
| Aspirin | 0 ( NaN) | 270 (87.7) | NaN |
| Clopidogrel | 0 ( NaN) | 212 (71.4) | NaN |
| Statins | 0 ( NaN) | 272 (90.1) | NaN |
| ACE-I/ARB | 0 ( 0.0) | 234 (57.4) | <0.001 |
| Beta blockers | 0 ( NaN) | 233 (77.9) | NaN |
| Referral to rehabilitation program | 12 ( 3.1) | 88 (26.5) | <0.001 |
| Participating in a rehabilitation program | 7 ( 1.9) | 14 ( 4.2) | 0.104 |
| Clinical outcomes | |||
| In-hospital complictions | |||
| Killip 3 | 97 (21.7) | 44 (10.8) | <0.001 |
| Killip 4 | 39 ( 8.8) | 30 ( 7.4) | 0.544 |
| Re MI | 12 ( 2.7) | 4 ( 1.0) | 0.110 |
| Post MI angina | 45 (10.2) | 15 ( 3.7) | <0.001 |
| Stent thrombosis | 0 ( 0.0) | 5 ( 1.2) | 0.509 |
| Ischemic stroke | 6 (85.7) | 7 (77.8) | 1.000 |
| Free wall rupture | 9 ( 2.0) | 8 ( 2.0) | 1.000 |
| High degreeAV block | 23 ( 5.2) | 22 ( 5.4) | 1.000 |
| TIA/CVA | 9 ( 2.0) | 11 ( 2.7) | 0.654 |
| Acute renal failure | 76 (17.1) | 49 (12.0) | 0.048 |
| Major bleeding | 13 ( 2.9) | 17 ( 4.2) | 0.416 |
| Death rates | |||
| In-hospital death | 70 (15.6) | 42 (10.3) | 0.029 |
| 7-day mortality | 49 (10.9) | 33 ( 8.1) | 0.206 |
| 30-day mortality | 78 (17.3) | 56 (13.8) | 0.179 |
| 1-year mortality | 140 (31.2) | 101 (25.0) | 0.054 |
## Call: survfit(formula = Surv(time1y, status1y) ~ late.period, data = na.omit(dat[dat$group ==
## 1, c("time1y", "status1y", "late.period")]))
##
## late.period=0
## time n.risk n.event survival std.err lower 95% CI upper 95% CI
## 0 449 0 1.000 0.0000 1.000 1.000
## 2 351 93 0.793 0.0191 0.756 0.831
## 4 338 13 0.763 0.0201 0.725 0.804
## 6 323 15 0.729 0.0210 0.689 0.772
## 8 314 9 0.709 0.0215 0.668 0.752
## 10 311 3 0.702 0.0216 0.661 0.746
## 12 304 7 0.686 0.0220 0.645 0.731
##
## late.period=1
## time n.risk n.event survival std.err lower 95% CI upper 95% CI
## 0 404 0 1.000 0.0000 1.000 1.000
## 2 335 69 0.829 0.0187 0.793 0.867
## 4 326 9 0.807 0.0196 0.769 0.846
## 6 318 8 0.787 0.0204 0.748 0.828
## 8 311 7 0.770 0.0209 0.730 0.812
## 10 307 4 0.760 0.0213 0.719 0.803
## 12 303 4 0.750 0.0215 0.709 0.793| Dependent variable: | ||
| 1-Year Mortality | ||
| b b b - Model 0 b b b - | b b b - Model 1 b b b - | |
| Period: 2008-2016 | 0.77* (0.59, 0.99) | 1.07 (0.80, 1.43) |
| p = 0.05 | p = 0.66 | |
| Dyslipidemia=YES | 0.61*** (0.45, 0.81) | |
| p = 0.001 | ||
| Hypertension=YES | 0.84 (0.59, 1.19) | |
| p = 0.33 | ||
| Diabetes=YES | 1.48** (1.13, 1.95) | |
| p = 0.005 | ||
| Prior MI=YES | 1.02 (0.74, 1.41) | |
| p = 0.91 | ||
| PVD=YES | 1.88** (1.22, 2.89) | |
| p = 0.004 | ||
| Prior CABG=YES | 0.75 (0.41, 1.36) | |
| p = 0.34 | ||
| Prior PCI=YES | 0.61* (0.39, 0.97) | |
| p = 0.04 | ||
| History of CHF=YES | 0.94 (0.66, 1.35) | |
| p = 0.76 | ||
| s/p CVA/TIA=YES | 1.07 (0.75, 1.52) | |
| p = 0.73 | ||
| Prior AP 24 hours=YES | 0.72* (0.53, 0.98) | |
| p = 0.04 | ||
| Prior Chronic Renal Failure=YES | 1.49* (1.09, 2.06) | |
| p = 0.02 | ||
| Adm. killip class >1 | 2.09*** (1.59, 2.76) | |
| p = 0.0000 | ||
| Observations | 853 | 822 |
| Note: | p<0.05; p<0.01; p<0.001 | |
