http://orcid.org/0000-0001-6650-8075
Abstract
Aim: To examine trends in incidence and 28-day case fatality of myocardial infarction (MI) in persons aged 75–99 years in four areas of Finland.
Methods and results: The Finnish Acute Myocardial Infarction (FINAMI) register is a population-based MI register study, which during 1995–2012 recorded 30561 suspected acute coronary syndromes in persons aged ≥75 years. Of them, 16229 fulfilled the American Heart Association criteria for a definite, probable or possible MI or coronary death. This age-group contributed 56.8% of all MIs of which 62.7% occurred in women. The incidence of MI decreased by −3.3%/year (95% CI −4.2; −2.4) in women aged 75–84 years, and by −1.2%/year (−1.9; −0.5) in women aged 85-99 years, but among men in these age-groups, only a non-significant reduction occurred. The 28-day case fatality of MI was high. In the age-group 75–84 years, it decreased non-significantly by −1.6%/year in men, and significantly by −2.4%/year (−3.9; −0.8) in women. In the age-group 85–99 years, the decrease was more remarkable: −5.1%/year (−7.8; −2.3) and −3.9%/year (−5.5; −2.2), respectively.
Conclusions: In Finland, more than half of MIs occur in the age-group 75–99 years, and most of them in women. The incidence of MI decreased significantly in elderly women but non-significantly in elderly men. The 28-day case fatality decreased especially in the age-group 85–99 years.
In Finland, more than one half of all myocardial infarctions (MIs) occur in the age-group of 75 years or older. Furthermore, 62.7% of MIs among elderly patients occur among women, although 58.0% of the elderly population are women. The incidence of MI decreased significantly in elderly women but not in elderly men. The 28-day case fatality in elderly patients was high but decreased significantly during the study period 1995–2012.
This study provides population-based data on treatment strategies and trends in incidence, event rate, mortality and case fatality of MI in elderly individuals. Elderly patients with acute coronary syndromes still present a remarkable burden to the healthcare system in Finland as well as in many other developed countries. Especially considering the modern trend of reducing hospital resources and shifting patient care to outpatient clinics, the epidemiology of MI in elderly patients remains an important issue for the future planning of the healthcare system.
Key Messages
Introduction
Coronary heart disease (CHD) mortality has decreased in Finland as well as in several other Western populations [Citation1]. Although declining myocardial infarction (MI) hospitalization rates have been reported [Citation2], hospitalizations due to acute coronary syndrome (ACS) among elderly patients have increased until the early 2000s [Citation3]. In the age-group of 85 years or older, the total number of hospitalizations for ACS has decreased only slightly after the peak years of the early 2000s [Citation3]. Furthermore, the elderly population is rapidly increasing [Citation4], which has led to discrepant forecasts on the numbers of elderly coronary patients in the future [Citation5–7]. Elderly patients inevitably have more comorbidities and take longer to recover than younger patients. Thus, elderly patients with ACS present a remarkable burden to the healthcare system in many developed countries. Nonetheless, elderly individuals have been excluded from most clinical trials and even from many observational studies. Therefore, there is a lack of reliable data on the trends in incidence, case fatality and treatment practice patterns of coronary events in elderly individuals.
The purpose of this study was to examine trends in incidence, event rate and CHD mortality, as well as 28-day case fatality of MI, in persons aged 75–84 years and 85–99 years in four geographic areas of Finland during 1995–2012. Furthermore, we compared clinical characteristics and treatment strategies of MI among elderly patients with middle-aged patients.
Material and methods
The Finnish Acute Myocardial Infarction (FINAMI) register is a population-based MI register, which aims to evaluate all ACS cases suspected as MIs or CHD deaths among permanent residents of the monitored areas in Finland. The study protocol is based on the World Health Organization?s MONICA (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease) Project, with some modifications. Since 1993, registration has covered all age-groups in four geographical areas of Finland. The protocol of the FINAMI register has been described in detail previously [Citation8,Citation9]. At the moment, data for all age-groups are available for a 17-year period, 1995–2012 (missing data for 2010).
Primary sources of ACS cases were hospital discharge diagnoses and death certificates. Events were classified based on symptoms, electrocardiograms (ECGs) (assessment of serial ECGs based on a standardized protocol), biochemical markers of myocardial injury, and possible autopsy findings. Clinical data for the register, such as receipt of coronary angiography, percutaneous coronary intervention (PCI) or attempted PCI, or coronary artery bypass grafting (CABG), during the 28-day period after the index event, were obtained from medical records. Only the first PCI after one MI event was taken into consideration in the analyses. MI was defined according to the American Heart Association (AHA) criteria published in 2003 [Citation10]. Definite, probable, and possible fatal and non-fatal MIs were included in the present study. Incidence refers to emergence of first MIs in a population. Accordingly, event rate refers to emergence of all MIs (first and recurrent MIs) in a population.
Data on comorbidity were obtained from the National Hospital Discharge Register. We retrieved all primary or secondary inpatient hospital diagnoses (ICD codes) since 5 years before the index event in the FINAMI register. Furthermore, we used Charlson comorbidity index (CCI) in categorizing the severity of comorbidity [Citation11,Citation12]. CCI is a weighted scoring system that includes 17 distinct conditions associated with in-hospital mortality. Elderly patients have several comorbidities, and CCI is a validated and widely used method to summarize the effect of different comorbidities [Citation12,Citation13].
Statistical methods
CHD event rates were expressed per 100,000 inhabitants and age-standardized according to the direct method using the European standard population of 1976 by 5-year age-groups as the standard [Citation14].
Population counts of the four regions included in the study used for the denominators were obtained from the National Population Register. The 95% confidence intervals (CIs) for the event rates were calculated based on the normal approximation of the binomial distribution. The uneven sampling scheme in the FINAMI register was accounted for using sampling weights and survey estimation methods (R-package “survey”). The 28-day case fatality was age-standardized using weights derived from the combined age distribution of MI and stroke patients in the WHO MONICA Project [Citation15]. The trends in event rates were determined using log-linear Poisson regression models with the year as independent variable [Citation16]. The regression coefficient multiplied by 100 gives the per cent annual change. The 28-day case fatality trends were further adjusted for age, age2, study area and CCI. Age2 was used due to nonlinear age trend of case fatality.
Competing causes of death were obtained from the National Causes-of-Death Register. Only less than 6% of patients died from causes other than CHD within 28 days after MI. Practically, competing causes of death have no effect on our results. According to the FINAMI register protocol, for all hospitalized cases, the diagnosis formed from non-fatal information remains as the diagnostic class for a 28-day fatal event. For non-cases (diagnosis from non-fatal event records is “no MI”), or if there is no hospitalization within the prior 28 days, the diagnosis of the fatal event is used.
The statistical significance level was p < .05 (two-sided). The statistical analyses were performed with R version 3.2.2 (R Core Team 2015, Vienna, Austria) [Citation17].
Ethical standards
The ethics committee of the National Institute for Health and Welfare (formerly National Institute for Public Health) has approved the FINAMI project (decision dated 21 January 2004).
Informed consent was not required because of the register-based nature of the study. The study complies with the Declaration of Helsinki.
Results
During the 17-year study period of 1995-2012, a total of 55,272 suspected ACS events were registered in persons aged 35-99 years. Of these, 30,561 (55.3%) events occurred in persons aged 75–99 years, and of them 16,229 fulfilled the AHA criteria for a definite, probable or possible MI, or coronary death. This age-group contributed 10.2% of the male and 13.0% of the female risk population in the study areas, but 56.8% of MIs. Among elderly patients 62.7% of MIs occurred in women, although 58.0% of the elderly population were women. The proportion of all MIs that were definite MIs was smaller in elderly than in middle-aged patients (67.6% vs. 81.5%, p < .0001). In 2742 (58.4%) of 4695 fatal MI cases, the cause of death was confirmed by autopsy findings.
Event rate of MI, incidence rate of MI and CHD mortality rate were high in elderly age-groups, especially in the age-group 85-99 years (). During the study period, MI event rate decreased significantly among both genders in persons aged 75–84 years and among women aged 85–99 years. However, among men aged 85–99 years, there was no change in MI event rate. Incidence of MI decreased significantly by 3.3%/year among women aged 75–84 years, and by 1.2%/year among women aged 85–99 years, but among men in these age-groups only a non-significant reduction occurred. CHD mortality rate decreased significantly among both genders in all age-groups, except among men aged 85–99 years. However, among women aged 35–74 years, CHD mortality rate was the lowest, but its reduction was the most marked, 6.6%/year. For comparison, age-standardized and age-group-specific rates and trends in all-cause mortality in the population of the FINAMI study areas are shown in Supplementary Table 1. Despite the declining trends in CHD mortality rates, all-cause mortality rates have not decreased.
Table 1. Age-standardized rates and trends (average annual change) in coronary mortality, incidence, and event rate of myocardial infarction (MI) per 100000 inhabitants in the population aged 35–74, 75–84, or 85–99 years of the FINAMI areas during 1995–2012.
The 28-day case fatality of MI was high in elderly patients, but it decreased significantly among women in the age-group 75–84 years, and even more markedly in the age-group 85–99 years: by 5.1%/year among men and by 3.9%/year among women (). Overall, the decrease in 28-day case fatality in the age-group 75–99 years was highly significant: p < .0001 among men and p < .0001 among women (adjusted for age, age2, study area and CCI).
Table 2. Age-standardized 28-day case fatality of definite or probable myocardial infarction (MI), prehospital case fatality, and 28-day case fatality for hospitalized cases among persons aged 35–74, 75–84, or 85–99 years, and trends in case fatalities in the FINAMI areas during 1995–2012.
and cover definite, probable and possible MIs. We also performed the analyses by excluding the class of possible MI, and the results are shown in and . There were no major changes in trends in coronary mortality, incidence and event rate of MI. However, there was a remarkable change in case fatalities. Among men and women aged 35–74 years, case fatalities of MI declined by −22% to −30%. Among men and women aged 75–84 years and 85-99 years, 28-day case fatality of MI declined by −15% to −17%. The diagnostic class of possible MI contains fatal MI cases with incomplete data to classify them as probable MI or definite MI, e.g. patients who have died before blood samples for cardiac troponins have been drawn. The AHA criteria [Citation10] contain detailed definitions of the MI classes.
According to diagnoses obtained from the National Hospital Discharge Register, the average CCI increased among men aged 75–99 years from 2.28 (95% CI 2.05; 2.52) in 1995–1999 to 2.71 (2.59; 2.83) in 2006–2012. Among women aged 75-99 years, the average CCI increased from 2.14 (2.00; 2.27) to 2.52 (2.43; 2.61), respectively. Especially the prevalence of congestive heart failure (clinical diagnosis) increased among men aged 75–99 years from 12.0% (95% CI 8.2; 17.2) in 1995–1999 to 31.3% (28.0; 34.8) in 2006–2012. Among elderly women, the prevalence of congestive heart failure increased from 18.4% (15.1; 22.3) to 36.3% (33.4; 39.0), respectively. Cross-tabulation of the register diagnoses and clinical diagnoses revealed that 63% of the patients aged 75 years or older also had a clinical diagnosis of MI and 27% had a clinical diagnosis of heart failure. Of the patients with a diagnosis of heart failure, 50% also had a diagnosis of MI. In some cases, it may be challenging to differentiate MIs merely due to atherothrombotic events from those with underlying acute or chronic conditions potentially predisposing to ischaemic imbalance mechanism of MI. Proportions of seven essential underlying clinical conditions among patients with the diagnosis of definite, probable or possible MI are shown in Supplementary Table 2. Proportions of patients with the diagnosis of heart failure, moderate to severe renal failure (both defined as in CCI) or atrial fibrillation (diagnosed during the same period of hospitalization as MI) increased throughout the study period among both men and women. Correspondingly, proportions of patients with concurrent infections increased. This reflects aging and increasing comorbidity of the study population. However, it is possible that this is also related to sharpened registering of additional diagnoses during hospitalizations.
Among elderly men, the clinical picture of MI was typical less often than among middle-aged men (), and the same applies to women (). Symptoms were typical (chest pain lasting for >20 min), and ECG findings were definite (a diagnostic Q wave developed or “injury current” ST segment elevation lasting for >2 days was followed by T wave inversion in serial ECG recordings) among elderly men and women less often than among middle-aged men and women. Overall, among women, the clinical picture of MI was less often typical than among men. Over time, the main basis of MI diagnoses shifted from typical symptoms and definite ECG to elevated biochemical markers of myocardial injury (cardiac troponin T or I increased above the cut-off level, or creatine kinase isoenzyme MB mass in cases in which troponins could not have been used). This phenomenon was found among both genders and in all age-groups. Elderly patients had a positive history of CHD in more than half of the cases, and middle-aged patients in less than 30% of cases. Men had diabetes in 19%–26%, and women in 25%–28% of the cases. Diabetes was most common, 30% of the cases, among women aged 75–84 years, but among men there was no clear association between age and diabetes.
Figure 1. Clinical characteristics of definite first myocardial infarction among men (a) and women (b) aged 35–74, 75–84, and 85–99 years who survived >1 day after hospital admission during 1995–1999, 2000–2005, and 2006–2012 (ECG: electrocardiography changes).
) shows the changes in the treatment of definite first MI at three different periods of time, years 1995–1999, 2000–2005 and 2006–2012, and among men and women aged 35–74, 75–84 or 85–99 years who survived >1 day after hospital admission. The proportion of patients receiving thrombolysis diminished markedly over time among men and women aged 35–74 or 75–84 years. At the same time, the proportion of patients undergoing coronary angiography with or without revascularization procedure (PCI or CABG) increased markedly among both genders in these age-groups. The proportion of very elderly patients (85–99 years) receiving thrombolysis, or undergoing coronary angiography with or without revascularization procedure, was low at all times. However, the proportion of men aged 85–99 years undergoing coronary angiography and revascularization procedure increased significantly by the last study period 2006–2012.
Figure 2. Treatment strategies (proportions of patients undergoing treatments) of definite first myocardial infarction among men (a) and women (b) aged 35–74, 75–84, and 85–99 years who survived >1 day after hospital admission during 1995–1999, 2000–2005, and 2006–2012.
In 1995–1999, PCI and CABG were approximately equally common among women aged under 85 years, but among men in these age-groups PCI was more common (). In the course of time, the proportion of patients undergoing PCI has increased markedly, and in 2006–2012 PCI was more than four times more common than CABG in the age-groups 35–74 and 75–84 years in both genders. Data on the timing of coronary angiography and revascularization procedures have been systematically registered since the year 2003. shows that nearly half of the PCI procedures after definite first MI in the age-group 75–84 years were performed during the first 24 h. The probability of undergoing primary PCI (<6 h after admission to the hospital) in connection with definite first MI was twice as high for men as for women (). In the age-group 85–99 years, the probability of primary PCI was very low among both genders. CABG was very rarely performed <6 h after admission to the hospital in connection with definite first MI.
Figure 3. Revascularization procedures (proportions of patients undergoing treatments) in connection with definite first myocardial infarction among men and women aged 35–74, 75–84, and 85–99 years who survived >1 day after hospital admission during 1995–1999, 2000–2005, and 2006–2012 (PCI, percutaneous coronary intervention. CABG, coronary artery bypass grafting).
Table 3. Timing of coronary angiography, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) among patients with definite first myocardial infarction (n = 6446) in the FINAMI areas during 2003–2012.
Table 4. Probability of coronary angiography and revascularization procedure (percutaneous coronary intervention, PCI, and coronary artery bypass grafting, CABG) among patients with definite first myocardial infarction (n = 4085) in the FINAMI areas during 2003–2012.
Cognitive impairment and renal dysfunction are often contraindications to invasive treatments of ACS in elderly patients. Both dementia and moderate to severe renal dysfunction are components of CCI. Based on the ICD codes, among men aged 75–99 years undergoing revascularization, 5.2% had dementia, 6.3% had moderate to severe renal dysfunction, and 5.7% had both comorbidities. Among women aged 75–99 years, the proportions were 1.8%, 3.3% and 2.3%, respectively.
Discussion
The rapid decline in CHD mortality among middle-aged men and women reported earlier [Citation8,Citation16] has continued until 2012. CHD mortality is very high in elderly age-groups but during 1995–2012 it decreased, especially in the age-group 75–84 years. Furthermore, the 28-day case fatality of MI decreased significantly in all other age-groups, except among men aged 75–84 years. Surprisingly, the 28-day case fatality of MI decreased most markedly in the age-group 85–99 years. Slightly more than one half of all MIs occurred in the age-group of 75 years or older, and nearly two-thirds of them in women. This was shown already in our previous study [Citation9] covering the years 1995–2002 and confirmed in the present study extending the study period until 2012.
During the study period 1995-2012, incidence of MI decreased significantly among elderly women but not among elderly men. Incidence of MI halved among women aged 75–84 years and decreased by one-fifth among women aged 85–99 years. It is possible that primary prevention of CHD is better implemented among elderly women than men. Elderly women may also have a better adherence to primary preventive medications than elderly men. There are few previous studies on adherence of elderly patients to primary preventive medications. In the Finnish population [Citation18], adherence of retired women to antihypertensive drugs was slightly better than among men, but the difference was not statistically significant. However, type 2 diabetic women were significantly more adherent to their antidiabetic drugs than men. In a Danish register study, advanced age and female sex were associated with better compliance on secondary preventive medication after MI [Citation19]. Furthermore, in another Finnish register study, women discontinued use of statins after their first ACS significantly less often than men [Citation20].
MI event rate (first and recurrent MIs) decreased significantly among women aged 75–84 years. A smaller significant decrease in MI event rate occurred among men aged 75–84 years and among women aged 85–99 years. In a Norwegian population-based study, no changes in MI event rates were observed during 1994–2002 among patients aged 65 years or older [Citation21]. However, during 2002–2009, MI event rates declined significantly by 2.6%/year among elderly men and by 2.4%/year among elderly women [Citation21]. In the United States, MI hospitalization rate declined significantly from 2001 to 2007 in each age category, and overall by −29.2% [Citation2]. However, absolute decreases in the MI hospitalization rate were greater in older patients compared with younger patients [Citation2].
CHD mortality decreased more markedly than event rate of MI in all age-groups. Furthermore, 28-day case fatality of MI decreased significantly in all other age-groups, except among men aged 75–84 years. The 28-day case fatality increases strongly with age, but during the study period it decreased most markedly among both genders in the age-group 85–99 years, in which revascularization procedures were still uncommon. It is possible that CHD among very elderly patients is a different disease than among middle-aged patients. The symptoms are more often mild and atypical, the ECG changes may be less marked, and the elevation of biochemical markers of myocardial injury may be minor. Exacerbation of chronic heart failure with a minor release of cardiac troponins without other evidence of myocardial ischemia may in some cases have been diagnosed as a MI. Patients with severe CHD with or without diabetes, or with severe left ventricular systolic heart failure, have probably already died at a younger age. Patients who do not have their first MI until at a very old age of 85 years or older have already had a good prognosis of life. In very elderly patients some cardiovascular risk factors may actually be protective and extend lifetime.
According to the epidemiological update report on cardiovascular disease in Europe [Citation22,Citation23], CHD mortality rates have been decreasing in the majority of northern and western European countries during the past decades [Citation23]. Recently, CHD mortality rates have started decreasing in central and eastern Europe as well [Citation22]. Age-standardized CHD mortality rates among men and women were still in 2011 higher in Finland than in the majority of northern, western and southern European countries but lower than in eastern European countries [Citation22]. Diet, lifestyle and other modifiable risk factors of CHD clearly explain a large part of the differences in CHD mortality rates across Europe [Citation24]. In addition, revascularization strategies, use of medications for CHD [Citation25] and genetic factors probably play a role. Furthermore, in Finland, the life expectancy among men is still lower than among women. Hormonal factors, such as endogenous oestrogen, no longer protect postmenopausal women against CHD. In our study, the decrease of the CHD mortality rate may be partly explained by the decreasing 28-day case fatality, which may be affected by more active treatment and care for elderly patients in the 2000s.
In the 2000s, revascularization procedures, especially PCIs, in connection with MI have become more common among elderly patients, and they are performed more often on elderly men than women. CABG is very unusual in the age-group of 85 years or older, probably due to increased risks of anaesthesia and surgery. Coronary anatomy may be more complex in elderly than in younger patients. The vast majority of these very elderly patients are still treated conservatively, and only a small minority of them undergo revascularizations. In a recent Norwegian After Eighty study, 457 ACS patients aged older than 80 years were randomized to revascularization or optimal pharmacotherapy after coronary angiography [Citation26]. The patients who underwent revascularization (in most cases PCI) had a better 1.5-year prognosis with regard to MI and need for urgent revascularization. However, the benefit from revascularizations was reduced with increasing age. Patients aged 85 years or older benefited from invasive strategy less than those aged 80–84 years. Patients aged 90 years or older did not seem to benefit from invasive strategy, but their number was low.
In the Euroheart ACS survey in 2000–2001, the majority of patients presented with typical angina pain, but less frequently in elderly age-groups [Citation27]. Heart failure complicated MI more frequently and a coronary angiogram was performed less frequently with increasing age. Among patients aged 85 years or older presenting with ST-elevation within 12 h, only a minority was treated with primary reperfusion. These results are well in line with our study. As shown in , atypical symptoms were common among elderly patients with MI, especially women. These patients had atypical pain, acute failure of left ventricle (pulmonary oedema), shock or syncope not explained by other conditions than ACS. Furthermore, atypical pain was described as short of duration or intermittent (but each episode of pain lasting for <20 min) or placed atypically (such as upper arm, epigastrium, jaw, nape of the neck). In elderly patients, acute confusion with no other explanation than ACS was classified as atypical symptom.
In a recent study from Switzerland, the probability of any PCI and primary PCI increased among septua-, octo-, and also nonagenarians with ST-elevation MI between the 4-year periods 2001–2004, 2005–2008 and 2009–2012 [Citation28]. Furthermore, PCI has been performed in increasingly comorbid patients. These results are in line with our study, although the probabilities of PCI were lower in our study, covering also milder ACS than ST-elevation MI.
Women tend to undergo fewer coronary revascularizations and reperfusion therapies in connection with MI than men [Citation29]. This seems not to be totally explained by the fact that women have their MIs at an older age than men [Citation30]. According to the European Society of Cardiology (ESC) guidelines, reperfusion therapies should be offered to women as actively as to men in connection with MI presenting with ST-segment elevation [Citation31]. Furthermore, the guidelines remind that the symptoms of MI may be mild or atypical among elderly patients, which may lead to delayed or missed diagnoses of MI [Citation32]. Also in our study the clinical picture of MI among elderly patients was more often atypical than among middle-aged patients.
According to the ESC guidelines for the management of ACSs without persistent ST-segment elevation, the estimated life expectancy, comorbidity, quality of life and the patient’s own wishes should be taken into account in making treatment decisions for elderly patients [Citation32]. The benefits and risks of revascularizations must be carefully considered [Citation32]. As our study shows, more than half of ACS patients are older than 75 years. However, only a minority of patients participating in ACS trials are older than 75 years, and most participants have less comorbidity than elderly patients with ACS in daily clinical practice. In a German register study of nearly 2000 patients aged 75 years or older and with non-ST-elevation MI, an invasive strategy was associated with an improved in-hospital and 1-year prognosis with regard to death and non-fatal MI [Citation33]. However, coronary angiograms, revascularizations, and use of antithrombotic medications may predispose elderly patients to further problems, such as bleeding complications, and acute or worsening chronic renal failure.
A scientific statement of the AHA on secondary prevention of atherosclerotic cardiovascular disease in older adults has been published in 2013 [Citation33]. Recommendations on secondary prevention are mainly based on clinical trials from which elderly patients have typically been excluded, especially those aged 85 years or older. Those elderly patients who have been included in the trials are often in exceptionally good condition with few other diseases. Although it may be assumed that also elderly patients benefit from most secondary preventive medications, the data are scarce on the subject.
A major strength of the present study is that it is population-based and the data were collected using standardized methods. However, a limitation is that the study areas are centred in urban areas. Since CHD mortality and morbidity tend to be higher in rural than in urban areas, our study may give a slightly too optimistic picture on the epidemiology of CHD in the elderly population of Finland. Another limitation is that we did not have data on the use of pharmacotherapies among these patients with suspected ACS. Among elderly patients, especially women, dementia and moderate to severe renal dysfunction were strong contraindications for revascularization. However, we lacked detailed clinical data on severity of dementia and on potential dialysis. Comprehensive data on underlying acute or chronic conditions potentially predisposing to ischaemic imbalance mechanism of MI are not possible to obtain in a register study. However, Supplementary Table 2 shows, on the basis of combined data from the National Hospital Discharge Register, the Causes-of-Death Register and the FINAMI register, the frequency of some clinical conditions potentially predisposing the patients to ischaemic imbalance in the background of MI.
During the study period, the mean CCI increased slightly, and especially congestive heart failure became more and more common. Thus, in the 2000s, patients hospitalized for MI are not only older but also more comorbid than in the 1990s.
Conclusions
In Finland, more than one half of all MIs occur in the age-group of 75 years or older, and most of them in elderly women. The incidence of MI decreased significantly in elderly women but not in elderly men. The 28-day case fatality was high but decreased significantly in elderly patients during the study period 1995–2012.
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Download MS Word (33 KB)Acknowledgement
We are grateful to Tapio Salomaa, BA, for revising the wording of the manuscript.
Disclosure statement
Y. Antero Kesäniemi reports personal fees from MSD, outside the submitted work. Juhani Airaksinen reports grants from Finnish Foundation for Cardiovascular Research, during the conduct of the study, and personal fees from Boehringer Ingelheim, Pfizer, AstraZeneca, Cardiome, and Bayer, outside the submitted work.
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References
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