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Guideline-directed Medical Therapy in Nonagenarians and Centenarians (≥ 90 Years Old) After First-onset Myocardial
Hon Jen Wong1, Keith Zhi Xian Toh2, Chen Ee Low1
1Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Insights
Guideline-directed medical therapies (GDMTs) significantly improve survival in patients aged 90 and older following acute myocardial infarction (AMI). Prescribing any number of GDMTs, including combinations, offers a survival advantage in this elderly population.
Area of Science:
- Cardiology
- Geriatric Medicine
- Clinical Pharmacology
Background:
- Guideline-directed medical therapies (GDMTs) are proven to reduce mortality post-acute myocardial infarction (AMI).
- The survival benefits of GDMTs in the very elderly (nonagenarians and centenarians, ≥ 90 years) remain unclear.
- Acute myocardial infarction (AMI) in advanced age presents unique challenges for treatment efficacy.
Purpose of the Study:
- To evaluate the survival benefit of GDMTs in patients aged 90 years and older after a first-onset AMI.
- To determine the association between the number of GDMT classes prescribed and long-term survival.
- To assess the impact of individual GDMTs within treatment combinations.
Main Methods:
- Analysis of patients ≥ 90 years with first-onset AMI from the Singapore Myocardial Infarction Registry (2007-2020).
- Stratification by the number of GDMTs (0, 1-2, 3, or 4 classes) prescribed at discharge.
- Calculation of restricted mean survival times and survival ratios free from all-cause mortality at 1, 3, and 5 years.
Main Results:
- A total of 3264 patients were analyzed, with a median follow-up of 5.71 years.
- Increased number of GDMT classes at discharge correlated with longer survival free from all-cause mortality at 1, 3, and 5 years.
- Each drug class within 1-3 GDMT combinations showed a survival benefit, except for beta-blockers.
Conclusions:
- Prescription of any number of GDMTs is associated with significant survival benefit in nonagenarians and centenarians post-AMI.
- GDMTs are crucial for improving outcomes in the oldest AMI patients.
- Further research may refine GDMT use in this population, excluding beta-blockers from specific combinations.
Background:
Guideline-directed medical therapies (GDMTs), such as beta-blockers, antiplatelet drugs, lipid-lowering drugs, and renin-angiotensin system agents, have been associated with reduced risk of mortality after acute myocardial infarction (AMI). However, this survival benefit conferred by GDMTs in nonagenarians and centenarians (≥ 90 years old) is not well-defined.
Methods:
We investigated restricted mean survival times of patients ≥ 90 years of age with first-onset AMI treated with GDMTs from 2007 to 2020 in the Singapore Myocardial Infarction Registry. Primary analyses involved stratification by number of GDMTs prescribed at discharge, with derivation of pairwise restricted mean survival ratios free from all-cause mortality at 1, 3, and 5 years. Secondary analyses evaluated individual GDMTs within combinations of 1-3 GDMTs.
Results:
The analysis included 3264 patients: 0 GDMTs (561 patients, 17.2%), 1-2 GDMTs (1294 patients, 39.6%), 3 GDMTs (904 patients, 27.7%), and 4 GDMTs (505 patients, 15.5%), with a median follow-up duration of 5.71 years. Patients who received 4 GDMTs at discharge were younger, had more comorbidities, were more likely to be smokers, and were more likely to have undergone percutaneous coronary intervention than those prescribed fewer GDMTs. A greater number of GDMT classes at discharge was associated with longer survival free from all-cause mortality at 1, 3, and 5 years. Each drug class within combinations of 1-3 GDMTs was associated with significant survival benefit at all time points, except for beta-blockers.
Conclusions:
Prescription of any number of GDMTs to nonagenarians and centenarians after first-onset AMI is associated with significant survival benefit.
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