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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 3  |  Page : 96-99

Comparative evaluation of clinical profile, risk factors, and outcome of acute myocardial infarction in elderly and nonelderly patients


Department of Medicine, Cardiology, Indira Gandhi Government Medical College, Shimla, Himachal Pradesh, India

Date of Web Publication16-Sep-2016

Correspondence Address:
Rajesh Kumar
Indira Gandhi Government Medical College, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-449x.190738

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  Abstract 

Objective: To compare the clinical profile risk factors and in hospital outcome of acute myocardial infarction (AMI) in elderly patients (≥60 years) and nonelderly (<60 years) patients. Materials and Methods: This was a prospective observational cross-sectional analytical study which included all consecutive patients of AMI admitted to the Department of Medicine and Cardiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh over a period of 1 year (June 2011 to June 2012). The patients were divided into two groups, Group I patients of <60 years and Group II patients of ≥60 years. The age more than 60 years is considered elderly as per Indian Council of Medical Research survey on Indian Geriatric population 2007. Results: Between June 2011 and June 2012, 206 patients were enrolled in the study. Total of 97 (47.1%) patients were of ≥60 years of age designated as elderly with a mean age of 69.28 ± 5.72 years, and 109 (52.9%) patients were nonelderly with a mean age of 50.54 ± 7.16 years. Family history of coronary artery disease (CAD) and dyslipidemia was significantly higher as a risk factor in nonelderly whereas other conventional risk factors of CAD were equally present in both groups. Atypical pain chest, non-ST segment elevation MI along with post-MI complications and in hospital mortality was significantly higher in the elderly age group of the study population. Conclusion: The profile of CAD differs in elderly as compared to young patients. This study highlighted that atypical presentation of AMI as well post-MI complications and mortality is more common in elderly patients as compared to nonelderly patients.

Keywords: Acute myocardial infarction, coronary artery disease, coronary heart disease, non-ST-segment elevation myocardial infarction, ST-segment elevation myocardial infarction


How to cite this article:
Sharma A, Kumar R, Ashotra S, Thakur S. Comparative evaluation of clinical profile, risk factors, and outcome of acute myocardial infarction in elderly and nonelderly patients. Heart India 2016;4:96-9

How to cite this URL:
Sharma A, Kumar R, Ashotra S, Thakur S. Comparative evaluation of clinical profile, risk factors, and outcome of acute myocardial infarction in elderly and nonelderly patients. Heart India [serial online] 2016 [cited 2022 Oct 7];4:96-9. Available from: https://www.heartindia.net/text.asp?2016/4/3/96/190738


  Introduction Top


The 20 th century saw unparallel increase in life expectancy and a major shift in the cause of illnesses throughout the world. During this transition, cardiovascular diseases (CVD) became the most common cause of death worldwide which was accounting for <10% deaths only a century ago but now accounts for nearly 40% of deaths in high income and about 28% in low- and middle-income countries. [1] About one-sixth of world's population lives in India, and it is experiencing an alarming increase in heart diseases. WHO had estimated that 60% of world's cardiac patients were Indians in 2010. [2] Although there are very few studies on the prevalence of myocardial infarction (MI) in elderly in India, population studies has shown that around 15-53% hospital admission for MI are in elders whereas western literature has reported around 60% of hospital admissions due to MI in elderly. [3]

Several factors contribute to the increased incidence of MI in older age, first the prevalence rate of hypertension, diabetes, and hyperlipidemia are higher in older age group, the duration of exposure to these risk factors also tends to be longer in older people. Ageing is associated with important changes in homeostatic system, the net effect of which is to alter the intrinsic balance between thrombosis and fibrinolysis in favor of thrombosis along with increased incidence of various other chronic inflammatory conditions such as arthritis and periodontal diseases also contribute to increased risk and incidence of MI in this age group. [4]

The profile of CVD and coronary artery disease (CAD) differs in elderly as compared to young individuals and also differs amongst patients of developed and developing countries. GRACE registry in western setup has recorded non-ST-segment elevation MI (NSTEMI) in 60-70% of elders, [5] whereas CREATE registry recorded STEMI more in Indian patients throughout the age. [6] MI related complications and mortality rates increase exponentially with age as incidence of heart failure, atrial fibrillation, heart blocks life-threatening arrhythmias, myocardial rupture, free wall rupture, ventricular septal perforation, and papillary muscle rupture tends to occur more in elderly more so in elderly females than males. [7] The failure to promptly recognize and treat MI in older patients is one of the several factors contributing to worse prognosis in elderly patients. This study was aimed at studying the clinical presentation, reason for delay, complications, and in hospital outcome of acute MI (AMI) in elderly (>60 years) and comparing it with nonelderly patients (<60 years).


  Materials and methods Top


This was a prospective observational cross-sectional analytical study which included all consecutive patients of AMI admitted to the Department of Medicine and Cardiology, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh over a period of 1 year (June 2011 to June 2012). The patients were divided into two groups, Group I patients of <60 years and Group II patients of >60 years, as age more than 60 years is considered elderly as per Indian Council of Medical Research survey on Indian Geriatric population 2007.

Inclusion criteria

The subjects fulfilling the following criteria and willing to participate in the study after obtaining informed consent were included in the study:

  • Patients with history compatible with MI
  • Typical electrocardiogram changes suggestive of MI
  • Elevated enzymes (Trop-T/Trop-I). NSTEMI and STEMI were defined as per standard criteria's.


Exclusion criteria

Patients with stable and unstable angina were excluded in the study.

Statistical analysis

All cases included in the study were divided into two groups, Group I (>60 years) and Group II (≥60 years). Continuous clinical characteristics in both groups were compared by unpaired t-test and using Chi-square statistics compared categorical variables in both groups; data were presented in percentage and mean ±± standard deviation. The statistical significance was considered as P < 0.05.

Observation

In this prospective observational cross-sectional analytical study, a total of 206 patients meeting the prespecified inclusion and exclusion criteria, admitted to the Department of Medicine and Cardiology, IGMC, Shimla over a period of 1 year from June 2011 to June 2012 were included in the study.

Demography

There were 97 (47.1%) patients who were ≥60 years designated as elderly and 109 patients <60 years. Elderly patients were in age range of 60-90 years where as nonelderly were in the range of 25-59 years. The mean age in elderly was 69.28 ± 5.72 years and in nonelderly 50.54 ± 7.16 years. Majority of patients were male 150 (72.7%), however, in elderly group, sex differentiation was not statistically significant [Table 1].
Table 1: Age and sex distribution of study group

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Risk factor distribution

Among various risk factors the family history of coronary artery, dyslipidemia was significantly higher in nonelderly group, where as other conventional risk factors such as smoking, central obesity, hypertension, and diabetes were equally present in both group and was not statistically significant [Table 2].
Table 2: Risk factor distribution

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Typical pain chest was main presentation in nonelderly whereas atypical chest pain as presentation was significantly higher in elderly group other complaints as primary presentation in elderly group was dyspnea, palpitation, postural giddiness and nausea, vomiting diaphoresis and altered sensorium [Table 3].
Table 3: Distribution of symptoms

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In study population, majority of patients, i.e. 105 (50.97%) had NSTEMI at presentation and it was more in elderly group as compared to nonelderly and also elderly group had higher Killip class at presentation as compared to nonelderly which was also statistically significant [Table 4].
Table 4: Distribution of non - ST - segment elevation myocardial infarction/ST - segment elevation myocardial infarction

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Overall, 98 (47.57%) in the study group presented late, i.e., after 12 h of symptom onset in which patients from elderly group were 64 (66.6%) and nonelderly group 34 (33.2%). The various reasons noted as patient related factors, medical personnel related factors, and lack of communications which were more prevalent in case of elderly patients and were statistically significant [Table 5].
Table 5: Reason for delay to health care facility

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The post-MI complications as well as in hospital mortality was also more and statistically significant in elderly group as compared to nonelderly group in the study [Table 6].
Table 6: Complications of acute myocardial infarction

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  Discussion Top


Aging is associated with alteration in homeostatic system favoring thrombosis, [8] consistent changes in autonomic nervous system influencing cardiovascular function, vascular changes like increased vascular stiffness endothelial dysfunction, [9] increased intimal thickness along with clustering and prolonged duration of exposure to various cardiovascular risk factors are responsible for increased incidence and severity of atherosclerotic CAD in elderly population. Total population of >65 years of age in the USA comprises 12.4% only, but they account for >60% of AMI and approximately 85% of all deaths due to MI. [10] The VIGOUR trial, GRACE and NRMI registry constituted 14%, 28%, each of patients >75 years of age. In India Holey et al., found 53.3% of enrolled patients in their study were of >60 years of age. [11],[13] The life time risk of developing symptomatic CAD is estimated at 1 in 3 for men and 1 in 4 for women, with onset of symptoms about 10 years earlier in men as compared to women. Hypertension, diabetes, and lipid abnormalities influence individual risk by 20-30%. At age of 80 years, similar frequencies of symptomatic CAD are seen in both men and women. [12]

Total number of patients enrolled in this study was 206, which included 47.1% elderly and 52.9% nonelderly. In respectively, create registry patients below 50 years were 30% and 13% were above 70 years. Woon et al., reported 47.7% elderly and was consistent with our study. [13] Cardiovascular risk factor in this study revealed hypertension, dyslipidemia, and family history of CAD were common risk factor for AMI. Hypertension was significantly higher in elderly (56.7%) as compared to nonelderly patients (39.4%) P = 0.04; dyslipidemia was more common in nonelderly 45.9% compared to elderly 24.7% and also family history of CVD in nonelderly 7.3% than elderly 2.1% and was consistent with as reported by  Holay et al., and Dang and Dias [14] though typical pain chest was most common presenting symptom (71.35%) in both groups, however, atypical symptoms were more in elderly (50.5%) than nonelderly (9.2%). Atypical pain chest and dyspnea were the most common atypical symptom in both groups, but significantly more common in elderly (41.22%) than nonelderly (5.5%). This percentage of atypical presentation has been universally reported by Indian authors Holey and Dang. In our study, higher functional class heart failure and shock was more common in elderly than nonelderly. At the time of presentation (75.3%) elderly patients were in Killip class I as compared to (81.7%) nonelderly which was statistically significant, however significantly more number of elderly (18.5%) were present in higher Killip class 3 and 4 than nonelderly (11.1%). Time taken to reach coronary care unit after the onset of symptoms was more in elderly patients 26.76 ± 21.88 h where this 15.54 ± 13.72 h in nonelderly and difference was statistically significant (P = 0.00) in our study 65.97% of elderly patients had delayed presentation whereas 31.2% of patients presented late in nonelderly group. The reason for delay studied was patient-related, medical personnel related and communication-related factors. Although the common cause for delay was communication-related in both elderly (45.31%) and nonelderly (35.3%). However, in the elderly population, most common cause of delay was patient related 45.31% versus 29.2%. In nonelderly medical personnel, related factors were more common 35.5% versus 9.3% than elderly. Our study reported significant ally higher mortality for elderly 20.6% as compared to nonelderly 6.4% which was due to a combination of late presentation, under use of thrombolysis resulting in more complications, etc.

AMI patients are hospitalized almost equally in both elderly and nonelderly. Typical chest pain is the most common presentation in both groups; however, atypical symptoms are more common in elderly. There should be sensitization at community level about CAD, its risk factors, symptoms, and emphasis for early treatment strengthening of services at primary care and secondary care facilities to prevent delay.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Balleisen L, Bailey J, Epping PH, Schulte H, van de Loo J. Epidemiological study on factor VII, factor VIII and fibrinogen in an industrial population: I. Baseline data on the relation to age, gender, body-weight, smoking, alcohol, pill-using, and menopause. Thromb Haemost 1985;54:475-9.  Back to cited text no. 8
    
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Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association task force on practice guidelines: Developed in collaboration with the Canadian cardiovascular society endorsed by the American Academy of family physicians: 2007 writing group to review new evidence and update the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction, writing on behalf of the 2004 writing committee. Circulation 2008;117:296-329.  Back to cited text no. 11
    
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Holay MP, Janbandhu A, Javahirani A, Pandharipande MS, Suryawanshi SD. Clinical profile of acute myocardial infarction in elderly (prospective study). J Assoc Physicians India 2007;55:188-92.  Back to cited text no. 13
    
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Dang A, Dias A. Differences In Risk Factors And Mortality, In Young And Old Individuals With Acute Myocardial Infarction In Goa. J Clin Diagn Res 2008;2:715-9.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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