Age as a predictor of clinical outcomes and determinant of therapeutic measures for emergency medical services treated cardiogenic shock

BACKGROUND The impact of age on outcomes in cardiogenic shock(CS)is poorly described in the pre-hospital setting.We assessed the impact of age on outcomes of patients treated by emergency medical services(EMS).METHODS This population-based cohort study included consecutive adult patients with CS transported to hospital by EMS.Successfully linked patients were stratified into tertiles by age(18-63,64-77,and>77 years).Predictors of 30-day mortality were assessed through regression analyses.The primary outcome was 30-day all-cause mortality.RESULTS A total of 3523 patients with CS were successfully linked to state health records.The average age was 68±16 years and 1398(40%)were female.Older patients were more likely to have comorbidities including pre-existing coronary artery disease,hypertension,dyslipidemia,diabetes mellitus,and cerebrovascular disease.The incidence of CS was significantly greater with increasing age(incidence rate per 100,000 person years 6.47[95%CI:6.1-6.8]in age 18-63 years,34.34[32.4-36.4]in age 64-77 years,74.87[70.6-79.3]in age>77 years,P<0.001).There was a step-wise increase in the rate of 30-day mortality with increasing age tertile.After adjustment,compared to the lowest age tertile,patients aged>77 years had increased risk of 30-day mortality(adjusted hazard ratio=2.26[95%CI:1.96-2.60]).Older patients were less likely to receive inpatient coronary angiography.CONCLUSION Older patients with EMS-treated CS have significantly higher rates of short-term mortality.The reduced rates of invasive interventions in older patients underscore the need for further development of systems of care to improve outcomes for this patient group.

Risk stratification for coronary artery disease in multi-ethnic populations:Are there broader considerations for cost efficiency?

Coronary artery disease(CAD) screening and diagnosis are core cardiac specialty services.From symptoms,autopsy correlations supported reductions in coronary blood flow and dynamic epicardial and microcirculatory coronaries artery disease as etiologies.While angina remains a clinical diagnosis,most cases require correlation with a diagnostic modality.At the onset of the evidence building process much research,now factored into guidelines were conducted among population and demographics that were homogenous and often prior to newer technologies being available.Today we see a more diverse multi-ethnic population whose characteristics and risks may not consistently match the populations from which guideline evidence is derived.While it would seem veryunlikely that for the majority,scientific arguments against guidelines would differ,however from a translational perspective,there will be populations who differ and importantly there are cost-efficacy questions,e.g.,the most suitable first-line tests or what parameters equate to an adequate test.This article reviews non-invasive diagnosis of CAD within the context of multi-ethnic patient populations.