[Management of acute myocardial infarction in the experience of a community hospital. A prospective study].Minerva Cardioangiol. 1997 Jul-Aug; 45(7-8):335-47.MC
BACKGROUND AND AIM
The capacity of the results of clinical studies to lead to changes in clinical practice is controversial. The treatment of elderly patients with acute myocardial infarction (AMI) represents an increasingly important challenge for the physician. The decreasing mortality rate for AMI in the general population is countered by an increasingly high mortality rate among the elderly. The aim of this prospective study was to evaluate the impact of the results of clinical studies on the treatment of AMI in community hospitals, and to highlight any differences in treatment and prognosis depending on age.
MATERIALS AND METHODS
123 patients with AMI were divided into two groups: (1) young patients (61.2%) aged under 75 (76 patients of whom 64 were male, with a mean age of 61.08 +/- 9.63) and (2) elderly patients (38.8%) aged over 75 (47 patients of whom 26 were male, with a mean age of 81.77 +/- 3.94). All patients were monitored for at least 12 months after discharge.
The percentage administration of fibrinolytics (60.5%), aspirin (80.3%), beta-blockers (oral 40.8%; i.v. 32.9%) and anticoagulants (97.4%) showed that young patients were treated according to the indications reported in the literature. Thrombolysis was more frequently performed in young patients than in the aged (60.5% vs 10.6%; p = 0.0001). Multiple logistic regression analysis showed that age, Killip's class and time at hospitalization were variables predicting the exclusion from fibrinolysis. During hospitalization the elderly group received oral beta-blockers less frequently (8.5% vs 40.8%; p = 0.0001); on discharge, they less frequently received ACE-inhibitors (14.9% vs 46.1%; p = 0.0004), aspirin (48.9% vs 77.6%; p = 0.001), beta-blockers (12.8% vs 44.7%; p = 0.0002). The elderly group revealed a higher mortality rate both during hospitalization (19.1% vs 3.9%; p = 0.01) and follow-up (44.7% vs 11.0%; p = 0.0001). Multivariate analysis showed a direct correlation between ventricular arrhythmia and Killip's class and hospital mortality, whereas smoking and time at hospitalization were inversely correlated. Mortality during follow-up was directly associated with Killip's class and inversely to the use of ACE-inhibitors during hospitalization, and beta-blockers and diuretics on discharge. Kaplan-Meier analysis did not show any differences in the survival rate of the two groups, but the first year after AMI was particularly critical for elderly patients among whom 40% of all deaths were recorded.
This study confirms the application in clinical practice of the results of clinical studies also in community hospitals, and shows that elderly AMI patients are high-risk patients. The high mortality in the latter group is correlated to the fact that they are less eligible to undergo fibrinolytic therapy and have a lower probability of receiving drugs of proven efficacy as a means of increasing survival after AMI. Further clinical studies are required to reduce mortality after AMI in a population that is increasingly widely represented in community hospitals.