Researchers have found that prescribing guideline-directed medical therapy (GDMT) – regardless of the number of medications – can improve survival rates in patients aged 90 and older after their first heart attack. The greatest benefit was observed in patients who received all four recommended therapies for the post-acute myocardial infarction (AMI) period. These include beta-blockers, antiplatelet agents, lipid-lowering drugs, and renin-angiotensin-aldosterone system inhibitors. The findings of the article published in the Canadian Journal of Cardiology (Elsevier) can serve as a guide for future clinical approaches to treating the first AMI in nonagenarians and centenarians. Life expectancy has been steadily increasing over time. In 2021, there were more than 861,000 Canadians aged 85 and older, an age group that is rapidly growing in developed countries worldwide. As age is an independent risk factor for developing cardiovascular disease, there is a growing need for guidelines on how to manage this older population. The lead author of the article, “Guideline-Directed Medical Therapy in Nonagenarians and Centenarians (? 90 Years Old) After First Myocardial Infarction – A Nationwide Registry Study,” Ching-Hui Sia, MBBS, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, and Department of Cardiology, National University Heart Centre Singapore, says: “As clinicians, we are often hesitant to prescribe GDMT to nonagenarians and centenarians with an acute myocardial infarction. This hesitation stems from concerns about polypharmacy, high comorbidity burden, frailty, and the risk of adverse drug events such as orthostatic hypotension, which can lead to falls. We wanted to clarify in clinical practice whether prescribing more medications to this age group could actually be associated with worse survival outcomes.” The researchers conducted a retrospective cohort study using the Singapore National Myocardial Infarction Registry. It included 3,264 patients aged 90 and older who had a non-ST-elevation myocardial infarction between 2007 and 2020. They compared survival between groups stratified by the number of GDMTs prescribed at discharge (0, 1–2, 3, or 4). The analysis showed that prescribing any number of GDMTs was associated with improved survival, with the greatest benefit observed in patients who received all four recommended therapies.
This is the most extensive study to date evaluating the outcomes of myocardial infarction (MI) in patients aged 90 years and older. It is based on data from a national registry within a high-performing, well-resourced health care system. The current and important findings provide practical insights that can contribute to safer prescribing practices for very elderly patients.
The co-author of the accompanying editorial, “ Medical Management of Patients 90 Years and Older After Acute Coronary Syndrome — Never Too Old “, Karen B. Ho, MD, Department of Cardiology, Faculty of Medicine, Mazankowski Heart Institute, Edmonton, points out: “Despite the considerable attention paid to the adverse effects of polypharmacy, underprescribing in older adults is an increasingly recognized and important problem. Appropriate management of acute coronary syndrome (ACS) in this age group is challenging due to a lack of evidence and concerns about medication tolerability and safety. The current study is encouraging in suggesting that GDMT after ACS is associated with improved survival in this very advanced age group, and the more complete the therapy, the better. Therefore, unless contraindicated, physicians should not withhold GDMT on the basis of age alone.”
