Cohort Profile: the European Unified Registries On Heart care Evaluation and Randomised Trials (EuroHeart) - Acute Coronary Syndrome and Percutaneous Coronary Intervention.

AIMS: The European Unified Registries On Heart care Evaluation And Randomized Trials (EuroHeart) aims to improve the quality of care and clinical outcomes for patients with cardiovascular disease. The collaboration of acute coronary syndrome/percutaneous coronary intervention (ACS/PCI) registries is operational in seven vanguard European Society of Cardiology member countries. METHODS AND RESULTS: Adults admitted to hospitals with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) are included, and individual patient-level data collected and aligned according to the internationally agreed EuroHeart data standards for ACS/PCI. The registries provide up to 155 variables spanning patient demographics and clinical characteristics, in-hospital care, in-hospital outcomes, and discharge medications. After performing statistical analyses on patient data, participating countries transfer aggregated data to EuroHeart for international reporting.Between 1st January 2022 and 31st December 2022, 40 021 admissions (STEMI 46.7%, NSTEMI 53.3%) were recorded from 192 hospitals in the seven vanguard countries: Estonia, Hungary, Iceland, Portugal, Romania, Singapore, and Sweden. The mean age for the cohort was 67.9 (standard deviation 12.6) years, and it included 12 628 (31.6%) women. CONCLUSION: The EuroHeart collaboration of ACS/PCI registries prospectively collects and analyses individual data for ACS and PCI at a national level, after which aggregated results are transferred to the EuroHeart Data Science Centre. The collaboration will expand to other countries and provide continuous insights into the provision of clinical care and outcomes for patients with ACS and undergoing PCI. It will serve as a unique international platform for quality improvement, observational research, and registry-based clinical trials.

Psychosocial outcomes from one cohort participating in the STan Australian Randomised controlled Trial (START).

BACKGROUND: In an Australian randomized controlled trial (RCT), two techniques for intrapartum fetal surveillance were compared: ST analysis (STan) as an adjunct to cardiotocography (CTG), compared with CTG alone. The aim was to determine whether CTG + STan could reduce emergency cesarean birth rates while maintaining or improving neonatal outcomes. Secondary aims were to compare clinical, economic, and psychosocial outcomes. The purpose of this paper was to present psychosocial outcomes from one cohort enrolled in the trial. METHODS: The study was conducted at one tertiary referral hospital. Participants who had taken part in the trial from the outset were invited to complete a questionnaire between March 2018 and January 2020, approximately 8 weeks after giving birth. Outcomes included depression, psychological distress, health-related quality of life, and infant feeding practices. Analysis was by intention to treat. RESULTS: N = 207/527 participants completed the questionnaire (n = 113, STan; n = 94, CTG alone). Overall, no statistically significant or clinically meaningful differences were found in the two groups for symptoms of depression, psychological distress, quality of life, or infant feeding. A statistically significant difference was observed for the subscale of pain-discomfort, where scores were higher on average in the CTG alone arm relative to that in the CTG + STan arm. CONCLUSIONS: Although STan as an adjunct to CTG constitutes a different clinical technology from CTG alone, both monitoring types appeared to produce similar results in terms of postnatal psychosocial outcomes for women. Findings from this study provide service users and staff with a comprehensive assessment of STan that can be used to make evidence-informed decisions about monitoring options should STan become more widely available.

Automated external defibrillator location and socioeconomic deprivation in Great Britain.

OBJECTIVE: The early use of automated external defibrillators (AEDs) improves outcomes in out-of-hospital cardiac arrest (OHCA). We investigated AED access across Great Britain (GB) according to socioeconomic deprivation. METHODS: Cross-sectional observational study using AED location data from The Circuit: the national defibrillator network led by the British Heart Foundation in partnership with the Association of Ambulance Chief Executives, Resuscitation Council UK and St John Ambulance. We calculated street network distances between all 1 677 466 postcodes in GB and the nearest AED and used a multilevel linear mixed regression model to investigate associations between the distances from each postcode to the nearest AED and Index of Multiple Deprivation, stratified by country and according to 24 hours 7 days a week (24/7) access. RESULTS: 78 425 AED locations were included. Across GB, the median distance from the centre of a postcode to an AED was 726 m (England: 739 m, Scotland: 743 m, Wales: 512 m). For 24/7 access AEDs, the median distances were further (991 m, 994 m, 570 m). In Wales, the average distance to the nearest AED and 24/7 AED was shorter for the most deprived communities. In England, the average distance to the nearest AED was also shorter in the most deprived areas. There was no association between deprivation and average distance to the nearest AED in Scotland. However, the distance to the nearest 24/7 AED was greater with increased deprivation in England and Scotland. On average, a 24/7 AED was in England and Scotland, respectively, 99.2 m and 317.1 m further away in the most deprived than least deprived communities. CONCLUSION: In England and Scotland, there are differences in distances to the nearest 24/7 accessible AED between the most and least deprived communities. Equitable access to 'out-of-hours' accessible AEDs may improve outcomes for people with OHCA.

Inequalities in care delivery and outcomes for myocardial infarction, heart failure, atrial fibrillation, and aortic stenosis in the United Kingdom.

Cardiovascular diseases are a leading cause of death and disability globally, with inequalities in burden and care delivery evident in Europe. To address this challenge, The Lancet Regional Health-Europe convened experts from a range of countries to summarise the current state of knowledge on cardiovascular disease inequalities across Europe. This Series paper presents evidence from nationwide secondary care registries and primary care healthcare records regarding inequalities in care delivery and outcomes for myocardial infarction, heart failure, atrial fibrillation, and aortic stenosis in the National Health Service (NHS) across the United Kingdom (UK) by age, sex, ethnicity and geographical location. Data suggest that women and older people less frequently receive guideline-recommended treatment than men and younger people. There are limited publications about ethnicity in the UK for the studied disease areas. Finally, there is inter-healthcare provider variation in cardiovascular care provision, especially for transcatheter aortic valve implantation, which is associated with differing outcomes for patients with the same disease. Providing equitable care is a founding principle of the UK NHS, which is well positioned to deliver innovative policy responses to reverse observed inequalities. Understanding differences in care may enable the implementation of appropriate strategies to mitigate differences in outcomes.

Temporal trends of cause-specific mortality after diagnosis of atrial fibrillation.

BACKGROUND AND AIMS: Reports of outcomes after atrial fibrillation (AF) diagnosis are conflicting. The aim of this study was to investigate mortality and hospitalization rates following AF diagnosis over time, by cause and by patient features. METHODS: Individuals aged ≥16 years with a first diagnosis of AF were identified from the UK Clinical Practice Research Datalink-GOLD dataset from 1 January 2001, to 31 December 2017. The primary outcomes were all-cause and cause-specific mortality and hospitalization at 1 year following diagnosis. Poisson regression was used to calculate rate ratios (RRs) for mortality and incidence RRs (IRRs) for hospitalization and 95% confidence intervals (CIs) comparing 2001/02 and 2016/17, adjusted for age, sex, region, socio-economic status, and 18 major comorbidities. RESULTS: Of 72 412 participants, mean (standard deviation) age was 75.6 (12.4) years, and 44 762 (61.8%) had ≥3 comorbidities. All-cause mortality declined (RR 2016/17 vs. 2001/02 0.72; 95% CI 0.65-0.80), with large declines for cardiovascular (RR 0.46; 95% CI 0.37-0.58) and cerebrovascular mortality (RR 0.41; 95% CI 0.29-0.60) but not for non-cardio/cerebrovascular causes of death (RR 0.91; 95% CI 0.80-1.04). In 2016/17, deaths caused from dementia (67, 8.0%), outstripped deaths from acute myocardial infarction, heart failure, and acute stroke combined (56, 6.7%, P < .001). Overall hospitalization rates increased (IRR 2016/17 vs. 2001/02 1.17; 95% CI, 1.13-1.22), especially for non-cardio/cerebrovascular causes (IRR 1.42; 95% CI 1.39-1.45). Older, more deprived, and hospital-diagnosed AF patients experienced higher event rates. CONCLUSIONS: After AF diagnosis, cardio/cerebrovascular mortality and hospitalization has declined, whilst hospitalization for non-cardio/cerebrovascular disease has increased.

Angiographic and Procedural Characteristics in Frail Older Patients with Non-ST Elevation Acute Coronary Syndrome.

Background: Angiographic and procedural characteristics stratified by frailty status are not known in older patients with non-ST elevation acute coronary syndrome (NSTEACS). We evaluated angiographic and procedural characteristics in older adults with NSTEACS by frailty category, as well as associations of baseline and residual SYNTAX scores with long-term outcomes. Methods: In this study, 271 NSTEACS patients aged ≥75 years underwent coronary angiography. Frailty was assessed using the Fried criteria. Angiographic analysis was performed using QAngio® XA Medis in a core laboratory. Major adverse cardiovascular events (MACE) consisted of all-cause mortality, MI, stroke or transient ischaemic attack, repeat unplanned revascularisation and significant bleeding. Results: Mean (±SD) patient age was 80.5 ± 4.9 years. Compared with robust patients, patients with frailty had more severe culprit lesion calcification (OR 5.40; 95% CI [1.75-16.8]; p=0.03). In addition, patients with frailty had a smaller mean improvement in culprit lesion stenosis after percutaneous coronary intervention (50.6%; 95% CI [45.7-55.6]) than robust patients (58.6%; 95% CI [53.5-63.7]; p=0.042). There was no association between frailty phenotype and completeness of revascularisation (OR 0.83; 95% CI [0.36-1.93]; p=0.67). A high baseline SYNTAX score (≥33) was associated with adjusted (age and sex) 5-year MACE (HR 1.40; 95% CI [1.08-1.81]; p=0.01), as was a high residual SYNTAX score (≥8; adjusted HR 1.22; 95% CI [1.00-1.49]; p=0.047). Conclusion: Frail adults presenting with NSTEACS have more severe culprit lesion calcification. Frail adults were just as likely as robust patients to receive complete revascularisation. Baseline and residual SYNTAX score were associated with MACE at 5 years.

New horizons in the role of digital data in the healthcare of older people.

There are national and global moves to improve effective digital data design and application in healthcare. This New Horizons commentary describes the role of digital data in healthcare of the ageing population. We outline how health and social care professionals can engage in the proactive design of digital systems that appropriately serve people as they age, carers and the workforce that supports them. KEY POINTS: Healthcare improvements have resulted in increased population longevity and hence multimorbidity. Shared care records to improve communication and information continuity across care settings hold potential for older people. Data structure and coding are key considerations. A workforce with expertise in caring for older people with relevant knowledge and skills in digital healthcare is important.

Sex-based Differences in Percutaneous Coronary Intervention Outcomes in Patients with Ischaemic Heart Disease.

In high-income countries, ischaemic heart disease is the leading cause of death in women and men, accounting for more than 20% of deaths in both sexes. However, women are less likely to receive guideline-recommended percutaneous coronary intervention (PCI) than men. Women undergoing PCI have poorer unadjusted outcomes because they are older and have greater comorbidity than men, but uncertainty remains whether sex affects outcome after these differences in clinical characteristics are considered. In this paper, we review recent published evidence comparing outcomes between men and women undergoing PCI. We focus on the sex differences in PCI outcomes in different scenarios: acute coronary syndromes, stable angina and complex lesions, including the approach of left main coronary artery. We also review how gender is considered in recent guidelines and offer a common clinical scenario to illustrate the contemporary management strategies an interventional cardiologist should consider when performing PCI on a female patient.

Attainment of NICE blood pressure targets among older people with newly diagnosed hypertension: nationwide linked electronic health records cohort study.

BACKGROUND: it is not known if clinical practice reflects guideline recommendations for the management of hypertension in older people and whether guideline adherence varies according to overall health status. AIMS: to describe the proportion of older people attaining National Institute for Health and Care Excellence (NICE) guideline blood pressure targets within 1 year of hypertension diagnosis and determine predictors of target attainment. METHODS: a nationwide cohort study of Welsh primary care data from the Secure Anonymised Information Linkage databank including patients aged ≥65 years newly diagnosed with hypertension between 1st June 2011 and 1st June 2016. The primary outcome was attainment of NICE guideline blood pressure targets as measured by the latest blood pressure recording up to 1 year after diagnosis. Predictors of target attainment were investigated using logistic regression. RESULTS: there were 26,392 patients (55% women, median age 71 [IQR 68-77] years) included, of which 13,939 (52.8%) attained a target blood pressure within a median follow-up of 9 months. Success in attaining target blood pressure was associated with a history of atrial fibrillation (OR 1.26, 95% CI 1.11, 1.43), heart failure (OR 1.25, 95% CI 1.06, 1.49) and myocardial infarction (OR 1.20, 95% CI 1.10, 1.32), all compared to no history of each, respectively. Care home residence, the severity of frailty, and increasing co-morbidity were not associated with target attainment following adjustment for confounder variables. CONCLUSIONS: blood pressure remains insufficiently controlled 1 year after diagnosis in nearly half of older people with newly diagnosed hypertension, but target attainment appears unrelated to baseline frailty, multi-morbidity or care home residence.

Sex differences in treatment and outcomes amongst myocardial infarction patients presenting with and without obstructive coronary arteries: a prospective multicentre study.

Aims: Women have an increased prevalence of myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA). Whether sex differences exist in the outcomes of patients with MI and obstructive coronary arteries (MIOCA) vs. MINOCA remains unclear. We describe sex-based differences in diagnosis, treatment, and clinical outcomes of patients with MINOCA vs. MIOCA. Methods and results: A large-scale cohort study of patients with ST/non-ST elevation MI undergoing coronary angiography (01/2015-12/2019). Patient demographics, diagnosis, prescribed discharge medications, in-hospital complications, and follow-up data were prospectively collected. A total of 13 202 participants were included (males 68.2% and females 31.8%). 10.9% were diagnosed with MINOCA. Median follow-up was 4.62 years. Females (44.8%) were as commonly diagnosed with MINOCA as males (55.2%), unlike the male preponderance in MIOCA (male, 69.8%; female, 30.2%). Less secondary prevention medications were prescribed at discharge for MINOCA than MIOCA. There was no difference in mortality risk between MINOCA and MIOCA [in-hospital: adjusted odds ratio (OR) 1.32, 95% confidence interval (CI) 0.74-2.35, P = 0.350; long term: adjusted hazard ratio (HR) 1.03, 95% CI 0.81-1.31, P = 0.813]. MINOCA patients had reduced mortality at long-term follow-up if prescribed secondary prevention medications (aHR 0.64, 95% CI 0.47-0.87, P = 0.004). Females diagnosed with MIOCA had greater odds of in-hospital and 1-year mortality than males (aOR 1.50, 95% CI 1.09-2.07, P = 0.014; aHR 1.18, 95% CI 1.01-1.38, P = 0.048). Conclusion: MINOCA patients have similar mortality rates as MIOCA patients. MINOCA patients were less likely than those with MIOCA to be discharged with guideline-recommended secondary prevention therapy; however, those with MINOCA who received secondary prevention survived longer. Females with MIOCA experienced higher mortality rates vs. males.

Plasma biomarkers of endothelial function, inflammation and oxidative stress in individuals with non-freezing cold injury.

NEW FINDINGS: What is the central question of this study? Are biomarkers of endothelial function, oxidative stress and inflammation altered by non-freezing cold injury (NFCI)? What is the main finding and its importance? Baseline plasma [interleukin-10] and [syndecan-1] were elevated in individuals with NFCI and cold-exposed control participants. Increased [endothelin-1] following thermal challenges might explain, in part, the increased pain/discomfort experienced with NFCI. Mild to moderate chronic NFCI does not appear to be associated with either oxidative stress or a pro-inflammatory state. Baseline [interleukin-10] and [syndecan-1] and post-heating [endothelin-1] are the most promising candidates for diagnosis of NFCI. ABSTRACT: Plasma biomarkers of inflammation, oxidative stress, endothelial function and damage were examined in 16 individuals with chronic NFCI (NFCI) and matched control participants with (COLD, n = 17) or without (CON, n = 14) previous cold exposure. Venous blood samples were collected at baseline to assess plasma biomarkers of endothelial function (nitrate, nitrite and endothelin-1), inflammation [interleukin-6 (IL-6), interleukin-10 (IL-10), tumour necrosis factor alpha and E-selectin], oxidative stress [protein carbonyl, 4-hydroxy-2-nonenal (4-HNE), superoxide dismutase and nitrotyrosine) and endothelial damage [von Willebrand factor, syndecan-1 and tissue type plasminogen activator (TTPA)]. Immediately after whole-body heating and separately, foot cooling, blood samples were taken for measurement of plasma [nitrate], [nitrite], [endothelin-1], [IL-6], [4-HNE] and [TTPA]. At baseline, [IL-10] and [syndecan-1] were increased in NFCI (P < 0.001 and P = 0.015, respectively) and COLD (P = 0.033 and P = 0.030, respectively) compared with CON participants. The [4-HNE] was elevated in CON compared with both NFCI (P = 0.002) and COLD (P < 0.001). [Endothelin-1] was elevated in NFCI compared with COLD (P < 0.001) post-heating. The [4-HNE] was lower in NFCI compared with CON post-heating (P = 0.032) and lower than both COLD (P = 0.02) and CON (P = 0.015) post-cooling. No between-group differences were seen for the other biomarkers. Mild to moderate chronic NFCI does not appear to be associated with a pro-inflammatory state or oxidative stress. Baseline [IL-10] and [syndecan-1] and post-heating [endothelin-1] are the most promising candidates for diagnosing NFCI, but it is likely that a combination of tests will be required.

Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes.

We summarise the international guidelines surrounding risk stratification as well as discuss new emerging data for future development of a new risk model in the management of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS accounts for the bulk of acute coronary syndrome presentations in the UK, but management strategies in this group of patients have remained a subject of debate for decades. Patients with NSTE-ACS represent a heterogeneous population with a wide variation in short-term and long-term clinical outcomes, which makes a uniform, standardised treatment approach ineffective and inappropriate. Studies in the modern era have provided some guidance in treating this subset of patients: the provision of early, more potent therapies has been shown to improve outcomes in patients at a particularly elevated risk of adverse outcomes. International guidelines recommend adopting an individualised treatment approach through the use of validated risk prediction models to identify such patients at high risk of adverse outcomes. The present available evidence, however, is based on dated demographics, different diagnostic thresholds and outdated therapies. In particular, the evidence has limited applicability to female patients and older people with frailty. Moreover, the current risk models do not capture key prognostic variables, leading to an inaccurate estimation of patients' baseline risk and subsequent mistreatment. Therefore, the current risk models are no longer fit for purpose and there is a need for risk prediction scores that account for different population demographics, higher sensitivity troponin assays and contemporary treatment options.

Methodology for the development of international clinical data standards for common cardiovascular conditions: European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart).

AIMS: Data standards are consensual specifications for the representation of data arising from different sources. If provided with internationally harmonized variables, permissible values, and clinical definitions, they have the potential to enable reliable between- and within-country analysis of care and outcomes. The European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart) is a European Society of Cardiology project that allows participating countries to collect patient data to undertake quality improvement, observational studies, drug and device surveillance, and registry-based randomized controlled trials for cardiovascular conditions. This paper describes the methodology for development of harmonized data standards for EuroHeart. METHODS AND RESULTS: We adopted a five-step process for the development of harmonized data standards. The process includes (i) identification of clinical domains for data standard development by evaluating specific cardiovascular conditions with high prevalence and opportunities for quality improvement; (ii) construction of data standard specifications by systematic review of the literature; (iii) selection of variables by a domain-specific Working Group using a modified Delphi method; (iv) validation of data standards by a domain-specific Reference Group; and (v) implementation of the developed data standards into an IT platform. CONCLUSION: This paper describes the approach adopted by EuroHeart for the development of clinical data standards for cardiovascular disease. The methodology has been developed and is used by EuroHeart to create a suite of international data standards for cardiovascular diseases. The EuroHeart data standards may be used to systematically capture individual patient data about clinical care and for research.

Documentation of atrial fibrillation among non-conveyed ambulance patients: a new primary prevention opportunity?

Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a significant risk factor for stroke. Prescription of oral anticoagulant (OAC) medication reduces the risk of AF-related stroke by 64% - yet over 400,000 people in England have undiagnosed (and therefore untreated) AF.Emergency medical services (EMS) encounter a wide range of patients, some of whom may not engage with other healthcare services. AF may be detected by EMS in connection with the cause of the call, or as an incidental finding. While EMS are not traditionally utilised for public health screening, they may offer an opportunity to identify patients with undiagnosed or untreated AF and refer onward.This study aimed to explore what proportion of patients seen by EMS who were not transported to hospital had AF and to estimate how many would potentially benefit from OAC. Methods: A retrospective service evaluation was conducted using routinely collected data from a large UK regional ambulance service. The sample included adults attended by EMS on the 15th of each month in 2019, who were not transported to hospital and where an electrocardiogram was recorded. Of those with AF, we calculated the proportion in whom this was possibly new and report whether OAC was prescribed. Results: There were 859 patients who met the inclusion criteria, of whom 91 (11%) had AF documented. Of the 91 patients with AF, 23 (25%) had no documented history of AF or OAC prescription, so were potentially new diagnoses of AF, who would benefit from consideration of OAC therapy. Conclusion: The EMS assessment offers an opportunity for AF to be identified in patients who were not transported to hospital. EMS may have a role in primary prevention of harm, including stroke, by identifying and referring patients with AF for consideration of OAC.

Sex differences in long-term outcomes in older adults undergoing invasive treatment for non-ST elevation acute coronary syndrome: An ICON-1 sub-study.

Background: Cardiovascular disease is the leading cause of mortality for females globally, yet females are underrepresented in studies of acute coronary syndrome (ACS). Studies investigating sex-related differences in clinical outcomes of patients with non-ST elevation ACS (NSTEACS) have reported divergent results, and it is unknown whether long-term outcomes for older people with NSTEACS differ between males and females. Methods: The multi-centre prospective cohort study, ICON-1, consisted of patients aged ≥75 years undergoing coronary angiography following NSTEACS. The primary composite endpoint was all-cause mortality, myocardial infarction, unplanned revascularisation, stroke, and bleeding. We report outcomes at five-years by sex. Results: Of 264 patients, 102 (38.6%) females and 162 (61.4%) males completed the five-year follow-up and were included in the analytic cohort. At admission, females were older than males (82 ± 4.3 years vs 80.0 ± 4.1 years p = 0.018). Co-morbidity profile and GRACE score were similar between the groups. There were no differences in the provision of invasive or pharmacological treatments between sexes. At five-years, there were no association between sex and the primary outcome. Conclusion: In older adults with invasive treatment of NSTEACS, provision of guideline-indicated care and long-term clinical outcomes were similar between males and females.

Five-year clinical outcomes in patients with frailty aged ≥75 years with non-ST elevation acute coronary syndrome undergoing invasive management.

Aim: Frailty is associated with adverse outcomes in older patients with acute coronary syndrome (ACS). The impact of frailty on long-term clinical outcomes following invasive management of non-ST elevation ACS (NSTEACS) is unknown. Methods and results: The multi-centre Improve Clinical Outcomes in high-risk patieNts with ACS 1 (ICON-1) prospective cohort study consisted of patients aged >75 years undergoing coronary angiography following NSTEACS. Patients were categorized by frailty assessed by Canadian Study of Health and Ageing Clinical Frailty Scale (CFS) and Fried criteria. The primary composite endpoint was all-cause mortality, unplanned revascularization, myocardial infarction, stroke, and bleeding. Of 263 patients, 33 (12.5%) were frail, 152 (57.8%) were pre-frail, and 78 (29.7%) were robust according to CFS. By Fried criteria, 70 patients (26.6%, mean age 82.1 years) were frail, 147 (55.9%, mean age 81.3 years) were pre-frail, and 46 (17.5%, mean age 79.9 years) were robust. The composite endpoint was more common at 5 years among patients with frailty according to CFS (frail: 22, 66.7%; pre-frail: 81, 53.3%; robust: 27, 34.6%, P = 0.003), with a similar trend when using Fried criteria (frail: 39, 55.7%; pre-frail: 72, 49.0%; robust: 16, 34.8%, P = 0.085). Frailty measured with both CFS and Fried criteria was associated with the primary endpoint [age and sex-adjusted hazard ratio (HR) compared with robust groups. CFS: 2.22, 95% confidence interval (CI) 1.23-4.02, P = 0.008; Fried: HR 1.81, 95% CI 1.00-3.27, P = 0.048]. Conclusion: In older patients who underwent angiography following NSTEACS, frailty is associated with an increased risk of the primary composite endpoint at 5 years. Registration: Clinicaltrials.gov NCT01933581.

Is the contemporary care of the older persons with acute coronary syndrome evidence-based?

Globally, ischaemic heart disease is the leading cause of death, with a higher mortality burden amongst older adults. Although advancing age is associated with a higher risk of adverse outcomes following acute coronary syndrome (ACS), older patients are less likely to receive evidence-based medications and coronary angiography. Guideline recommendations for managing ACS are often based on studies that exclude older patients, and more contemporary trials have been underpowered and produced inconsistent findings. There is also limited evidence for how frailty and comorbidity should influence management decisions. This review focuses on the current evidence base for the medical and percutaneous management of ACS in older patients and highlights the distinct need to enrol older patients with ACS into well-powered, large-scale randomized trials.

Impact of multimorbidity on long-term outcomes in older adults with non-ST elevation acute coronary syndrome in the North East of England: a multi-centre cohort study of patients undergoing invasive care.

OBJECTIVES: Older adults have a higher degree of multimorbidity, which may adversely affect longer term outcomes from non-ST elevation acute coronary syndrome (NSTE-ACS). We investigated the impact of multimorbidity on cardiovascular outcomes 5 years after invasive management of NSTE-ACS. DESIGN: Prospective cohort study. SETTING: Multicentre study conducted in the north of England. PARTICIPANTS: 298 patients aged ≥75 years with NSTE-ACS and referred for coronary angiography, with 264 (88.0%) completing 5-year follow-up. MAIN OUTCOME MEASURES: Multimorbidity was evaluated at baseline with the Charlson comorbidity index (CCI). The primary composite outcome was all-cause mortality, myocardial infarction, stroke, urgent repeat revascularisation or significant bleeding. RESULTS: Mean age was 80.9 (±6.1) years. The cohort median CCI score was 5 (IQR 4-7). The primary composite outcome occurred in 48.1% at 5 years, at which time 31.0% of the cohort had died. Compared with those with few comorbidities (CCI score 3-5), a higher CCI score (≥6) was positively associated with the primary composite outcome (adjusted HR (aHR) 1.64 (95% CI 1.14 to 2.35), p=0.008 adjusted for age and sex), driven by an increased risk of death (aHR 2.20 (1.38 to 3.49), p=0.001). For each additional CCI comorbidity, on average, there was a 20% increased risk of the primary composite endpoint at 5 years (aHR 1.20 (1.09 to 1.33), p<0.001). CONCLUSIONS: In older adults with NSTE-ACS referred for coronary angiography, the presence of multimorbidity is associated with an increased risk of long-term adverse cardiovascular events, driven by a higher risk of all-cause mortality. TRIAL REGISTRATION NUMBER: NCT01933581; ClinicalTrials.gov.