Advertisement

A Risk Score for Predicting 1-Year Mortality in Patients ≥75 Years of Age Presenting With Non-ST-Elevation Acute Coronary Syndrome

      Approximately 1/3 of patients with non–ST-segment elevation (NSTE) acute coronary syndromes (ACS) are ≥75 years of age. Risk stratification in these patients is generally difficult because supporting evidence is scarce. The investigators developed and validated a simple risk prediction score for 1-year mortality in patients ≥75 years of age presenting with NSTE ACS. The derivation cohort was the Italian Elderly ACS trial, which included 313 patients with NSTE ACS aged ≥75 years. A logistic regression model was developed to predict 1-year mortality. The validation cohort was a registry cohort of 332 patients with NSTE ACS meeting the same inclusion criteria as for the Italian Elderly ACS trial but excluded from the trial for any reason. The risk score included 5 statistically significant covariates: previous vascular event, hemoglobin level, estimated glomerular filtration rate, ischemic electrocardiographic changes, and elevated troponin level. The model allowed a maximum score of 6. The score demonstrated a good discriminating power (C statistic = 0.739) and calibration, even among subgroups defined by gender and age. When validated in the registry cohort, the scoring system confirmed a strong association with the risk for all-cause death. Moreover, a score ≥3 (the highest baseline risk group) identified a subset of patients with NSTE ACS most likely to benefit from an invasive approach. In conclusion, the risk for 1-year mortality in patients ≥75 years of age with NSTE ACS is substantial and can be predicted through a score that can be easily derived at the bedside at hospital presentation. The score may help in guiding treatment strategy.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Alexander K.P.
        • Newby L.K.
        • Cannon C.P.
        • Armstrong P.W.
        • Gibler W.B.
        • Rich M.W.
        • Van de Werf F.
        • White H.D.
        • Weaver W.D.
        • Naylor M.D.
        • Gore J.M.
        • Krumholz H.M.
        • Ohman E.M.
        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; 115: 2549-2569
        • Angeli F.
        • Verdecchia P.
        • Savonitto S.
        • Morici N.
        • De Servi S.
        • Cavallini C.
        Early invasive versus selectively invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: impact of age.
        Catheter Cardiovasc Interv. 2014; 83: 686-701
      1. From the Centers for Disease Control and Prevention. Public health and aging: trends in aging–United States and worldwide.
        JAMA. 2003; 289: 1371-1373
        • Alexander K.P.
        • Roe M.T.
        • Chen A.Y.
        • Lytle B.L.
        • Pollack Jr., C.V.
        • Foody J.M.
        • Boden W.E.
        • Smith Jr., S.C.
        • Gibler W.B.
        • Ohman E.M.
        • Peterson E.D.
        • Crusade Investigators
        Evolution in cardiovascular care for elderly patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative.
        J Am Coll Cardiol. 2005; 46: 1479-1487
        • De Luca L.
        • Olivari Z.
        • Bolognese L.
        • Lucci D.
        • Gonzini L.
        • Di Chiara A.
        • Casella G.
        • Chiarella F.
        • Boccanelli A.
        • Di Pasquale G.
        • Bovenzi F.M.
        • Savonitto S.
        A decade of changes in clinical characteristics and management of elderly patients with non-ST elevation myocardial infarction admitted in Italian cardiac care units.
        Open Heart. 2014; 1: e000148
        • Amsterdam E.A.
        • Wenger N.K.
        • Brindis R.G.
        • Casey Jr., D.E.
        • Ganiats T.G.
        • Holmes Jr., D.R.
        • Jaffe A.S.
        • Jneid H.
        • Kelly R.F.
        • Kontos M.C.
        • Levine G.N.
        • Liebson P.R.
        • Mukherjee D.
        • Peterson E.D.
        • Sabatine M.S.
        • Smalling R.W.
        • Zieman S.J.
        2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2014; 130: e344-e426
        • Antman E.M.
        • Cohen M.
        • Bernink P.J.
        • McCabe C.H.
        • Horacek T.
        • Papuchis G.
        • Mautner B.
        • Corbalan R.
        • Radley D.
        • Braunwald E.
        The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making.
        JAMA. 2000; 284: 835-842
        • Eagle K.A.
        • Lim M.J.
        • Dabbous O.H.
        • Pieper K.S.
        • Goldberg R.J.
        • Van de Werf F.
        • Goodman S.G.
        • Granger C.B.
        • Steg P.G.
        • Gore J.M.
        • Budaj A.
        • Avezum A.
        • Flather M.D.
        • Fox K.A.
        • GRACE Investigators
        A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry.
        JAMA. 2004; 291: 2727-2733
        • Roe M.T.
        • Chen A.Y.
        • Thomas L.
        • Wang T.Y.
        • Alexander K.P.
        • Hammill B.G.
        • Gibler W.B.
        • Ohman E.M.
        • Peterson E.D.
        Predicting long-term mortality in older patients after non-ST-segment elevation myocardial infarction: the CRUSADE long-term mortality model and risk score.
        Am Heart J. 2011; 162: 875-883
        • Savonitto S.
        • Cavallini C.
        • Petronio A.S.
        • Murena E.
        • Antonicelli R.
        • Sacco A.
        • Steffenino G.
        • Bonechi F.
        • Mossuti E.
        • Manari A.
        • Tolaro S.
        • Toso A.
        • Daniotti A.
        • Piscione F.
        • Morici N.
        • Cesana B.M.
        • Jori M.C.
        • De Servi S.
        Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial.
        JACC Cardiovasc Interv. 2012; 5: 906-916
        • Kansagara D.
        • Dyer E.
        • Englander H.
        • Fu R.
        • Freeman M.
        • Kagen D.
        Treatment of anemia in patients with heart disease: a systematic review.
        Ann Intern Med. 2013; 159: 746-757
        • Reboldi G.
        • Angeli F.
        • Verdecchia P.
        Multivariable analysis in cerebrovascular research: Practical notes for the clinician.
        Cerebrovasc Dis. 2013; 35: 187-193
        • Cockcroft D.W.
        • Gault M.H.
        Prediction of creatinine clearance from serum creatinine.
        Nephron. 1976; 16: 31-41
        • Morici N.
        • De Servi S.
        • Toso A.
        • Murena E.
        • Tamburrini P.
        • Antonicelli R.
        • del Pinto M.
        • Cavallini C.
        • Petronio A.S.
        • Giannini C.
        • Piscione F.
        • Bolognese L.
        • Savonitto S.
        Renal function estimation and one-year mortality in elderly patients with non-ST-segment elevation acute coronary syndromes.
        Int J Cardiol. 2014; 174: 127-128
        • Steyerberg E.W.
        • Vickers A.J.
        • Cook N.R.
        • Gerds T.
        • Gonen M.
        • Obuchowski N.
        • Pencina M.J.
        • Kattan M.W.
        Assessing the performance of prediction models: a framework for traditional and novel measures.
        Epidemiology. 2010; 21: 128-138
        • Sullivan L.M.
        • Massaro J.M.
        • D'Agostino Sr., R.B.
        Presentation of multivariate data for clinical use: the Framingham Study risk score functions.
        Stat Med. 2004; 23: 1631-1660
        • Steyerberg E.W.
        • Bleeker S.E.
        • Moll H.A.
        • Grobbee D.E.
        • Moons K.G.
        Internal and external validation of predictive models: a simulation study of bias and precision in small samples.
        J Clin Epidemiol. 2003; 56: 441-447
        • Nabais S.
        • Rocha S.
        • Joao C.
        • Marques J.
        • Torres M.
        • Magalhaes S.
        • Pereira M.A.
        • Correia A.
        Prognostic impact of moderate renal dysfunction in acute coronary syndromes.
        Rev Port Cardiol. 2008; 27: 303-312
        • Chowdhury E.K.
        • Langham R.G.
        • Owen A.
        • Krum H.
        • Wing L.M.
        • Nelson M.R.
        • Reid C.M.
        • Second Australian National Blood Pressure Study Management Committeem
        Comparison of predictive performance of renal function estimation equations for all-cause and cardiovascular mortality in an elderly hypertensive population.
        Am J Hypertens. 2015; 28: 380-386
        • Carson J.L.
        • Brooks M.M.
        • Abbott J.D.
        • Chaitman B.
        • Kelsey S.F.
        • Triulzi D.J.
        • Srinivas V.
        • Menegus M.A.
        • Marroquin O.C.
        • Rao S.V.
        • Noveck H.
        • Passano E.
        • Hardison R.M.
        • Smitherman T.
        • Vagaonescu T.
        • Wimmer N.J.
        • Williams D.O.
        Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease.
        Am Heart J. 2013; 165: 964-971
        • Maseri A.
        • Rebuzzi A.G.
        • Cianflone D.
        Need for a composite risk stratification of patients with unstable coronary syndromes tailored to clinical practice.
        Circulation. 1997; 96: 4141-4142
        • Hamm C.W.
        • Bassand J.P.
        • Agewall S.
        • Bax J.
        • Boersma E.
        • Bueno H.
        • Caso P.
        • Dudek D.
        • Gielen S.
        • Huber K.
        • Ohman M.
        • Petrie M.C.
        • Sonntag F.
        • Uva M.S.
        • Storey R.F.
        • Wijns W.
        • Zahger D.
        ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the Management of acute Coronary Syndromes (ACS) in Patients Presenting Without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2011; 32: 2999-3054
        • Savonitto S.
        • Caracciolo M.
        • Sacco A.
        • Klugmann S.
        Diagnosis and treatment of non-ST-elevation acute coronary syndromes. Common clinical lessons and a few differences between the ESC and the ACC/AHA guidelines published in 2007.
        G Ital Cardiol. 2008; 9: 314-319
        • Savonitto S.
        • De Servi S.
        • Petronio A.S.
        • Bolognese L.
        • Cavallini C.
        • Greco C.
        • Indolfi C.
        • Visconti L.O.
        • Piscione F.
        • Ambrosio G.
        • Galvani M.
        • Marzocchi A.
        • Santilli I.
        • Steffenino G.
        • Maseri A.
        Early aggressive vs. initially conservative treatment in elderly patients with non-ST-elevation acute coronary syndrome: the Italian Elderly ACS study.
        J Cardiovasc Med. 2008; 9: 217-226
        • Damman P.
        • Clayton T.
        • Wallentin L.
        • Lagerqvist B.
        • Fox K.A.
        • Hirsch A.
        • Windhausen F.
        • Swahn E.
        • Pocock S.J.
        • Tijssen J.G.
        • de Winter R.J.
        Effects of age on long-term outcomes after a routine invasive or selective invasive strategy in patients presenting with non-ST segment elevation acute coronary syndromes: a collaborative analysis of individual data from the FRISC II - ICTUS - RITA-3 (FIR) trials.
        Heart. 2012; 98: 207-213