Characteristics and Baseline Clinical Predictors of Future Fatal Versus Nonfatal Coronary Heart Disease Events in Older Adults The Cardiovascular Coronary Heart Disease

Background —Although (cid:1) 80% of annual coronary heart disease (CHD) deaths occur in adults aged (cid:1) 65 years and the population is aging rapidly, CHD event fatality and its predictors in the elderly have not been well described. Methods and Results —The first myocardial infarction (MI) or CHD death among the 5888 adults aged (cid:1) 65 years occurring during enrollment in the Cardiovascular Health Study during 1989–2001 was identified and adjudicated. Characteristics measured at examinations before the event were examined for associations with case fatality (death before hospitalization or hospital discharge) and for differences in predictors by demographics or clinical history. During a median follow-up of 8.2 years, 985 CHD events occurred, of which 30% were fatal. Case fatality decreased slightly over time, ranging from 28% to 30% per year in the early 1990s versus 23% by 2000–2001; with adjustment for age at MI and gender, there was a 6% lower odds of fatality with each successive year (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.90 to 0.98). Case fatality was similar by race and gender but higher with age and prior CHD (MI, angina, or revascularization). When considered alone, many subclinical disease measures, such as common carotid intima-media thickness, ankle-arm index, left ventricular mass by ECG, and a major ECG abnormality, and traditional risk factors, such as diabetes and hypertension, were associated with fatality. In multivariable analysis, independent predictors of fatality were prior congestive heart failure (OR, 3.20; 95% CI, 2.32 to 4.41), prior CHD rather than only history of MI (OR, 2.51; 95% CI, 1.84 to 3.43), diabetes (OR, 1.66; 95% CI, 1.10 to 2.31), and age (OR, 1.21 per 5 years; 95% CI, 1.07 to 1.37), adjusted for gender and each other. Prior congestive heart failure, regardless of left ventricular systolic function, age, gender, or prior CHD, conferred a (cid:1) 3-fold increased risk of fatality in almost all subgroups. Conclusions —Among community-dwelling older adults, CHD case fatality remains substantial, with easily identifiable risk factors that may be different from those that predict incident disease. In the elderly in whom the risk/benefit of therapies may be influenced by multiple competing comorbidities and care needs, risk stratification possibly may be improved further by focusing more aggressive care on specific patients, especially those with a history of congestive heart failure or prior CHD. ( Circulation . 2006;113:2177-2185.) confirmed and validated by review of medical records and relevant examinations. 18 Medication use was confirmed by prescription bottle inventory. 19 Blood tests were done on 12-hour fasting samples. Participants without known diabetes underwent glucose tolerance testing. All participants had 12-lead ECG, 2-dimensional M-mode and Doppler echocardiography, carotid ar- tery duplex ultrasonography, and spirometry. Duplicate examinations were performed on a subset of participants for data quality control. All participants were followed up semiannually with alter-nating telephone interviews and clinic visits. Major illnesses and interim hospitalizations were ascertained by participant or physician reports and study-initiated follow-up activities including periodic searches of Medicare utilization files. Hospital discharge codes were reviewed, and more detailed data were abstracted for all cardiovas- cular diagnoses. whether findings from middle-aged populations also to those aged (cid:1) 65 years or whether might there be different factors that are more important in the older population or more important for predicting fatality from an event rather than predicting incident events, as is often studied. In this prospective cohort study of community-dwelling older adults, 30% of the CHD events were fatal, with a substantial proportion of out-of-hospital deaths. Case fatality decreased significantly over time and was similar by race and gender but increased with age, especially among women. A few traditional risk factors such as diabetes and many measures of subclinical disease were associated with case fatality when considered alone. However, prior CHD and congestive heart failure appeared to be the strongest independent predictors. Prior congestive heart failure conferred a (cid:1) 3-fold increased risk of fatality in all subgroups regardless of left ventricular systolic function. Prior CHD (myocardial infarction, angina, or previous revascularization) predicted case fatality more strongly than history of prior myocardial infarction alone. These data may be of value for the clinician in improving risk stratification and identifying those elderly patients at the highest risk for fatal CHD events who are most in need of the most aggressive care with all available preventive measures.