Management and outcome of non-ST-elevation acute coronary syndromes in the elderly admitted to spoke hospitals with no cath-lab facility

Abstract

Abstract Background Current guidelines recommend an early invasive strategy in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, the role of an invasive strategy in elderly patients remains controversial and may be difficult to achieve in spoke hospitals with no cath-lab facility. Purpose We aimed to analyze characteristics and outcomes of patients ≥80 years with NSTE-ACS admitted to spoke hospitals. Methods Observational retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals, where a service strategy (same-day transfer between spoke hospital and hub center with a cath-lab facility to perform coronary angiography) was available. Results From 2013 to 2017, 639 patients were admitted for NSTE-ACS in a spoke hospital of our provincial cardiology network; of these, 181 (28%) were ≥80 years (median 84, IQR 82–89). In the elderly conservative strategy was chosen in 76 patients (42%). When the invasive strategy was chosen, 104 patients (93%) were managed with a Service strategy with no major adverse event observed during the back transfer from the invasive center to the referring spoke center, whereas the rest of the patients (8, 7%) were transferred from the spoke hospital to the hub center and completed their hospital stay without returning to the spoke center. Of patients initially managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 11 (10%) and the patients remained in the hub center. The median time to access to cath-lab was 50 hours (IQR 25–87), with 73 patients (70%) reaching the invasive procedure <72 h from the hospital admission and 23 (22%) <24 h. Conservative strategy was associated with older age, known previous CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD, and atrial fibrillation (all p<0.03; Table). At 1-year follow-up, the overall survival was significantly higher in patients treated with invasive strategy compared to patients managed conservatively (94%±2 vs. 54%±6, p<0.001; HR: 10.4 [4.7–27.5] p<0.001; Figure), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0–4.0]; p<0.001). Conclusion An invasive strategy may confer a survival benefits in the elderly with NSTE-ACS. When the invasive strategy is chosen, the same-day transfer between spoke hospital and hub center with the cath-lab facility (service strategy) is safe and granted the access to cath-lab in a timely fashion even in the elderly. Funding Acknowledgement Type of funding sources: None. Table 1Figure 1