Little regard given to biomarker status in the treatment of older patients with acute MI

A large cohort study assessing the impact of troponin status and creatine kinase-myocardial band (CK-MB) measurements on guideline-based management of older patients with acute myocardial infarction (MI), has revealed suboptimal adherence to guideline-based therapies irrespective of biomarker status. Historically, the diagnosis of acute MI has been made using CK-MB measurements. However, more recently, troponins have established an increasingly important role in the diagnosis and prognosis of patients with acute coronary syndromes, in particular, the diagnosis of MI. Indeed, troponin is now considered the ‘gold standard’ biomarker for the diagnosis of MI. However, currently no data exist regarding the impact of troponin status on guideline-based treatment of older patients with acute MI. Shah et al. investigated the type of care received by older patients (who are not typically included in randomised clinical trials) who underwent testing for both CK-MB and troponin and whose findings were positive for troponin only. The study involved a cohort of 33,096 patients aged at least 65 years (mean age 77.6 years) with clinically confirmed acute MI. Patients were divided into three groups: those whose findings were positive for CK-MB only, those who were positive for troponin only, and those who were positive for both CK-MB and troponin. Patients’ quality of care was evaluated using measures of aspirin and beta-blocker use within 24 hours of hospital arrival, thrombolysis within 30 minutes of hospital arrival, percutaneous transluminal coronary angioplasty performed within 90 minutes of hospital arrival, discharge prescription of aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors. Troponin-only patients were found to have the highest in-hospital mortality rate (14%) and the CK-MB-only patients had the lowest mortality rates (10%; p Adjusted analysis revealed that CK-MB-only patients were more likely to receive aspirin (odds ratio [OR], 1.46) and beta-blocker (OR, 1.21) within 24 hours of hospital arrival, and aspirin on hospital discharge (OR, 1.27), compared with troponin-only patients. Furthermore, troponin and CK-MB patients were more likely to receive aspirin (OR, 1.55) and beta-blocker (OR, 1.22) within 24 hours of arrival and on discharge compared with troponin-only patients (ORs, 1.31 and 1.33, respectively). The results demonstrated that in this cohort of older patients who tested positive for troponin only, were less likely to receive proven, effective, standard post-acute-MI therapies compared with those who tested positive for CK-MB only, or both CK-MB and troponin. Furthermore, adherence to guideline-based therapies was suboptimal for older patients with acute MI overall, irrespective of their biomarker status. Reference Shah, R. Selter, J. et al. 2007, ‘Association of troponin status with guideline-based management of acute myocardial infarction in older persons’ Archives of Internal Medicine; 167: 1621—1628....