Percutaneous coronary intervention versus conservative treatment for non ST-segment elevation myocardial infarction in patients above 80 years of age.

BACKGROUND: There is a paucity of data if there is a benefit for patients above 80 years of age with non-ST-segment elevation myocardial infarction (NSTEMI) to undergo percutaneous coronary intervention (PCI). OBJECTIVES: To investigate the association between PCI or conservative treatment and outcomes in NSTEMI patients above 80 years of age. METHODS: From the SWEDEHEART register were included 13,854 patients above 80 years of age with NSTEMI during 2011-2014 in Sweden. Cox regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CI) for the association between PCI compared with conservative treatment for the outcome all-cause mortality. RESULTS: In total 4158 (30%) patients underwent PCI, and 9696 (70%) were treated conservatively. The mean age was 86 (±4) years. During a mean 2.2 (±1.4) years there were 6458 (47%) deaths, where of 1078 (26%) in PCI treated, and 5380 (56%) in conservatively treated patients. Treatment with PCI compared with conservative treatment was associated with a 40% lower risk of death (adjusted HR 0.60, 95% CI 0.55-0.66). Similarly, patients in the PCI group had a 60% lower 30-day, and 51% lower 1-year all-cause mortality, respectively (adjusted HR 0.40, 95% CI 0.25-0.63, and HR, 0.49 95% CI 0.42-0.57, respectively). There were no differences in risk of bleedings (1.4% versus 1.3%). CONCLUSIONS: PCI compared with conservative treatment was associated with a lower mortality in patients above 80 years of age with NSTEMI without an increased risk of bleedings. PCI may be considered as the treatment of choice for elderly with NSTEMI.

A telephone-based case-management intervention reduces healthcare utilization for frequent emergency department visitors.

BACKGROUND: A small group of frequent visitors to emergency departments accounts for a disproportional large number of total emergency department visits. Previous interventions in this population have shown mixed results. OBJECTIVE: To determine whether a nurse-managed telephone-based case-management intervention can reduce healthcare utilization and improve self-assessed health status in frequent emergency department users. METHODS: We carried out a Zelen-design randomized-controlled trial among patients who were identified as frequent emergency department users (≥ 3 visits during the 6 months before inclusion) at the Karolinska University Hospital in Stockholm (Sweden). Patients included in the study (n = 268) were randomized to either the intervention group or the control group and followed for 1 year. Patients who declined to participate or could not be reached were also followed for the study outcome. RESULTS: The telephone-based case-management intervention reduced the total number of outpatient visits (relative risk 0.80; 95% confidence interval 0.75-0.84), the number of emergency department visits (relative risk 0.77; 95% confidence interval 0.69-0.86), the number of days patients were admitted to hospitals as well as the total healthcare costs for hospital admissions. There was no difference in mortality or other identified adverse outcomes between the intervention and the control groups. Patient self-assessed health status improved for the patients who received the case-management intervention. CONCLUSION: Our results indicate that the nurse-managed telephone-based case-management intervention represents a possible strategy to improve care for frequent emergency department users as well as decrease outpatient visits, admission days and healthcare costs.