Myocardial Infarction In Older Adults Research Articles

Changes in Disability Before and After Myocardial Infarction in Older Adults

Disability in older adults is thought to occur primarily as a consequence of clinical disease episodes. However, the temporal relationship between clinical disease and disability has received little systematic attention. Data from a prospective population-based study of 2812 older adults were analyzed to examine changes in disability before and after acute myocardial infarction. Disability outcomes included up to 9 yearly assessments of disability in activities in daily living, disability in basic physical functions, and disability in tasks requiring basic mobility and strength. A total of 279 myocardial infarctions occurred during 9 years of follow-up. After adjustment for age and sex, the average yearly increase in disability in activities of daily living and basic physical functions was not significantly greater in the 1-year period after myocardial infarction than in the 3-year period before myocardial infarction (P values >.20). Disability in basic mobility and strength showed a significantly greater increase in the year after myocardial infarction (P = .02). The results did not change after adjustment for comorbidity and chest pain or when restricted to incident cases of myocardial infarction or survivors. An additional exploratory analysis suggested that the rate of increase in some forms of disability may start to accelerate at about 1 year before the event, rather than after the event. The increase in disability after myocardial infarction may form a continuation of increases that occur before the event and challenge commonly held notions about the temporal relationship between clinical disease and disability. Changes in disability before acute disease episodes may be related to subclinical disease.

Relationship between selective cyclooxygenase-2 inhibitors and acute myocardial infarction in older adults: Solomon DH, Schneeweiss S, Glynn RJ, et al. Circulation 2004;109:2068–73

Relationship between selective cyclooxygenase-2 inhibitors and acute myocardial infarction in older adults: Solomon DH, Schneeweiss S, Glynn RJ, et al. Circulation 2004;109:2068–73

Relationship between selective cyclooxygenase-2 inhibitors and acute myocardial infarction in older adults.

Although cyclooxygenase-2 inhibitors (coxibs) were developed to cause less gastrointestinal hemorrhage than nonselective nonsteroidal antiinflammatory drugs (NSAIDs), there has been concern about their cardiovascular safety. We studied the relative risk of acute myocardial infarction (AMI) among users of celecoxib, rofecoxib, and NSAIDs in Medicare beneficiaries with a comprehensive drug benefit. We conducted a matched case-control study of 54 475 patients 65 years of age or older who received their medications through 2 state-sponsored pharmaceutical benefits programs in the United States. All healthcare use encounters were examined to identify hospitalizations for AMI. Each of the 10 895 cases of AMI was matched to 4 controls on the basis of age, gender, and the month of index date. We constructed matched logistic regression models including indicators for patient demographics, healthcare use, medication use, and cardiovascular risk factors to assess the relative risk of AMI in patients who used rofecoxib compared with persons taking no NSAID, taking celecoxib, or taking NSAIDs. Current use of rofecoxib was associated with an elevated relative risk of AMI compared with celecoxib (odds ratio [OR], 1.24; 95% CI, 1.05 to 1.46; P=0.011) and with no NSAID (OR, 1.14; 95% CI, 1.00 to 1.31; P=0.054). The adjusted relative risk of AMI was also elevated in dose-specific comparisons: rofecoxib < or =25 mg versus celecoxib < or =200 mg (OR, 1.21; 95% CI, 1.01 to 1.44; P=0.036) and rofecoxib >25 mg versus celecoxib >200 mg (OR, 1.70; 95% CI, 1.07 to 2.71; P=0.026). The adjusted relative risks of AMI associated with rofecoxib use of 1 to 30 days (OR, 1.40; 95% CI, 1.12 to 1.75; P=0.005) and 31 to 90 days (OR, 1.38; 95% CI, 1.11 to 1.72; P=0.003) were higher than >90 days (OR, 0.96; 95% CI, 0.72 to 1.25; P=0.8) compared with celecoxib use of similar duration. Celecoxib was not associated with an increased relative risk of AMI in these comparisons. In this study, current rofecoxib use was associated with an elevated relative risk of AMI compared with celecoxib use and no NSAID use. Dosages of rofecoxib >25 mg were associated with a higher risk than dosages < or =25 mg. The risk was elevated in the first 90 days of use but not thereafter.

N−3 Polyunsaturated fatty acids, fatal ischemic heart disease, and nonfatal myocardial infarction in older adults: the Cardiovascular Health Study

Little is known about the relation of the dietary intake of n-3 polyunsaturated fatty acids, ie, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) from fatty fish and alpha-linolenic acid from vegetable oils, with ischemic heart disease among older adults. We investigated the associations of plasma phospholipid concentrations of DHA, EPA, and alpha-linolenic acid as biomarkers of intake with the risk of incident fatal ischemic heart disease and incident nonfatal myocardial infarction in older adults. We conducted a case-control study nested in the Cardiovascular Health Study, a cohort study of adults aged > or = 65 y. Cases experienced incident fatal myocardial infarction and other ischemic heart disease death (n = 54) and incident nonfatal myocardial infarction (n = 125). Matched controls were randomly selected (n = 179). We measured plasma phospholipid concentrations of n-3 polyunsaturated fatty acids in blood samples drawn approximately 2 y before the event. A higher concentration of combined DHA and EPA was associated with a lower risk of fatal ischemic heart disease, and a higher concentration of alpha-linolenic acid with a tendency to lower risk, after adjustment for risk factors [odds ratio: 0.32 (95% CI: 0.13, 0.78; P = 0.01) and 0.52 (0.24, 1.15; P = 0.1), respectively]. In contrast, n-3 polyunsaturated fatty acids were not associated with nonfatal myocardial infarction. Higher combined dietary intake of DHA and EPA, and possibly alpha-linolenic acid, may lower the risk of fatal ischemic heart disease in older adults. The association of n-3 polyunsaturated fatty acids with fatal ischemic heart disease, but not with nonfatal myocardial infarction, is consistent with possible antiarrhythmic effects of these fatty acids.

Eligibility for Lipid-Lowering Drug Therapy in Primary Prevention

In May 2001, the Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program issued revised guidelines for diagnosing and treating high blood cholesterol.1 These guidelines represent a major advance in risk assessment. They were preceded by the ATP I guidelines (1988), which focused on primary prevention of coronary heart disease (CHD), and by the ATP II guidelines (1993),2 which discussed primary and secondary prevention. In the ATP II and ATP III guidelines, low-density lipoprotein cholesterol (LDL-C) is the primary target of risk-reduction therapy. See p 152 The ATP II recommendations were based on epidemiological, preclinical, and incomplete clinical trial evidence. Within a few years after their publication, the results of 5 large-scale trials of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (ie, “statins”) were reported. Two of these (West of Scotland Coronary Prevention Study [WOSCOPS] and Air Force/Texas Coronary Atherosclerosis Prevention Study [AFCAPS/TexCAPS]) were primary-prevention trials.3,4 The remaining 3 focused on secondary prevention.5-7 Based on these epic trials and other laboratory, epidemiological, and clinical evidence, the ATP III guidelines were developed (Tables 1 and 2⇓). View this table: Table 1103484. ATP III Guidelines: New Features View this table: Table 2103484. ATP III Guidelines: Global Risk Assessment The major statin trials and resulting meta-analyses provided a firm foundation for a truly evidence-based approach to guideline revision. Involving 5 different populations with widely varying absolute risk levels and using 3 different statins (simvastatin, pravastatin, lovastatin), they produced remarkably consistent reductions of 24% to 37% in relative risk for major CHD events. In WOSCOPS, 6595 men with moderate hypercholesterolemia (LDL-C=192 mg/dL±SD) received pravastatin 40 mg/day for up to 4.9 years. Results indicated a 31% relative decrease in major CHD events, with a 26% reduction in LDL-C levels. AFCAPS/TexCAPS evaluated lovastatin 20 to 40 mg/day for up to 5.2 years in 6605 generally healthy men and women with …

Plasma phospholipid n-3 polyunsaturated fatty acids, fatal ischemic heart disease, and non-fatal myocardial infarction in older adults.

0013 BACKGROUND. Studies in middle-aged populations suggest that the intake of both long-chain and intermediate chain n-3 polyunsaturated fatty acids (PUFAs) is associated with a reduction in fatal ischemic heart disease (IHD) but not with non-fatal myocardial infarction (MI). OBJECTIVES. To assess the associations of plasma phospholipid n-3 PUFAs, a biomarker of n-3 PUFA intake, with both incident fatal IHD and incident non-fatal MI in older adults. METHODS. We conducted a nested case-control study using data from the Cardiovascular Health Study, a prospective cohort study of adults 65 and older. We identified 54 incident cases of fatal IHD (fatal MI and coronary heart disease death) and 130 incident cases of non-fatal MI. Controls, randomly selected, were matched to the cases on age, gender, clinic, and month of blood draw at a ratio of 1:1. Sampled cases and controls were free of IHD or stroke at the time of the blood draw. Bloods were collected at the baseline CHS examination. Plasma phospholipid PUFAs were measured using gas chromatography. RESULTS. An increase of one standard deviation in plasma phospholipid levels of combined docosahexaenoic acid (22:6n3) and eicosapentaneoic acid (20:5n3) (1% of total fatty acids) was associated with a decreased risk of fatal IHD (Odds ratio: 0.38, 95% CI [0.18-0.82]) but was not associated with non-fatal MI (Odds ratio: 1.01, 95% CI [0.78-1.30]) after adjustment for age, education, systolic blood pressure, weight, and fasting plasma glucose levels. Similarly, an increase of one standard deviation in plasma phospholipid levels of linolenic acid (0.06% of total fatty acids) was associated with a decreased risk of fatal IHD (Odds ratio: 0.46, 95% CI [0.22-0.95]) but was not associated with non-fatal MI (Odds ratio: 1.00, 95% CI [0.76-1.31]). CONCLUSIONS. Higher plasma phospholipid levels of long-chain and intermediate chain n-3 PUFAs are associated with a decreased risk of incident fatal IHD but are not associated with incident non-fatal MI in older adults. These findings are consistent with studies suggesting an anti-arrhythmic effect of n-3 fatty acids.

Traditional Risk Factors and Subclinical Disease Measures as Predictors of First Myocardial Infarction in Older Adults

Risk factors for myocardial infarction (MI) have not been well characterized in older adults, and in estimating risk, we sought to assess the individual and joint contributions made by both traditional risk factors and measures of subclinical disease. In the Cardiovascular Health Study, we recruited 5888 adults aged 65 years and older from 4 US centers. At baseline in 1989-1990, participants underwent an extensive examination that included traditional risk factors such as blood pressure and fasting glucose level and measures of subclinical disease as assessed by electrocardiography, carotid ultrasonography, echocardiography, pulmonary function, and ankle-arm index. Participants were followed up with semiannual contacts, and all cardiovascular events were classified by the Morbidity and Mortality Committee. The main analytic technique was the Cox proportional hazards model. At baseline, 1967 men and 2979 women had no history of an MI. After follow-up for an average of 4.8 years, there were 302 coronary events, which included 263 patients with MI and 39 with definite fatal coronary disease. The incidence was higher in men (20.7 per 1000 person-years) than women (7.9 per 1000 person-years). In all subjects, the incidence was strongly associated with age, increasing from 7.8 per 1000 person-years in subjects aged 65 to 69 years to 25.6 per 1000 person-years in subjects aged 85 years and older. Glucose level and systolic blood pressure were associated with the incidence of MI, but smoking and lipid measures were not. After adjustment for age and sex, the significant subclinical disease predictors of MI were borderline or abnormal ejection fraction by echocardiography, high levels of intimal-medial thickness of the internal carotid artery, and a low ankle-arm index. Forced vital capacity and electrocardiographic left ventricular mass did not enter the stepwise model. Excluding subjects with clinical cardiovascular diseases such as prior angina or congestive heart failure at baseline had little effect on these results. Risk factors were generally similar in men and women. After follow-up of 4.8 years, systolic blood pressure, fasting glucose level, and selected subclinical disease measures were important predictors of the incidence of MI in older adults. Uncontrolled high blood pressure may explain about one quarter of the coronary events in this population.

Are Sleep Complaints an Independent Risk Factor for Myocardial Infarction?

PURPOSE: To investigate whether subjective sleep complaints are an independent predictor of myocardial infarction (MI) in a community of older adults and to gain clues as to why the association between sleep complaints and incident MI exists. METHODS: Using longitudinal data from the Piedmont study on 2960 adults aged 65 or older who were free of symptomatic heart disease at baseline, we screened 19 potential confounders to determine if any, alone or in combination, could explain the observed relationship between incident MI and sleep complaints. RESULTS: During the three-year follow-up period, there were 152 incident MIs. Restless sleep (incidence density ratio (IDR) = 1.58, 95% confidence interval (CI) = 1.11, 2.24) and trouble falling asleep (IDR = 1.68, 95% CI = 1.09, 2.60) predicted incident MI after adjusting for age, gender, and race. IDRs were not substantially impacted by controlling for smoking, blood pressure, diabetes or obesity. After adjustment for education, number of prescription medicines, self-rated health, and depression score, all IDRs were nullified. In particular, self-rated health and depression were strong independent risk factors for MI. CONCLUSIONS: A subjective sleep complaint increases the likelihood of a first MI in older adults without overt coronary heart disease (CHD) independently of classic coronary risk factors and appears to be a marker for a syndrome of depression and malaise that may have a causal relationship to MI.

Prevalence and determinants of definite, non-Q-wave and silent myocardial infarction in older adults: The rotterdam study

Prevalence and determinants of definite, non-Q-wave and silent myocardial infarction in older adults: The rotterdam study

Utility of Beta‐Blockade Treatment for Older Postinfarction Patients

The prevalence of myocardial infarction (MI) in older people is high. Whereas use of beta-blockers after MI is known to lower MI mortality in younger adults, its efficacy for adults more than 75 years of age remains less clear. We hypothesized that use of beta-blockers after MI in older adults would improve clinical outcomes. Retrospective cohort study. A community-based, tertiary-care teaching hospital. A total of 1011 consecutive MI patients aged 60 to 89 were admitted to Boston's Beth Israel Hospital between January 1988 and September 1989 and were screened for this study. One hundred eighteen patients met eligibility criteria, of whom 76 received metoprolol, > or = 25 mg/day for at least 5 days after their MI. Forty-two age and clinically matched patients were similarly suitable for beta-blocker therapy, but it was omitted by their physicians during and after hospitalization. The latter group served as controls. Mortality, reinfarction, and subsequent hospital admissions were measured. MI patients aged 60 to 89 years who were treated with metoprolol had an age-adjusted mortality reduction of 76% (RR 0.24; P < .001; 95% CI 0.11-0.54). Multivariate logistic regression analysis showed a 12% mortality reduction (95% CI 0.75-1.00) among older MI patients, attributable to metoprolol therapy. Reinfarction rates were unchanged in patients receiving metoprolol therapy, and subsequent rehospitalizations were significantly increased among the metoprolol patients. Use of metoprolol significantly reduced mortality in older MI patients. The fact that metoprolol-treated patients had neither reduced reinfarctions or rehospitalizations may relate to methologic limitations of this study. The mortality data support the hypothesis that older patients benefit from postinfarction beta-blockade.