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(Circulation. 2006;113:2177-2185.)
© 2006 American Heart Association, Inc.

Coronary Heart Disease

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

The Cardiovascular Health Study

Camille A. Pearte, MD, MPH; Curt D. Furberg, MD, PhD; Ellen S. O’Meara, PhD; Bruce M. Psaty, MD, PhD; Lewis Kuller, MD, DrPH; Neil R. Powe, MD, MPH, MBA; Teri Manolio, MD, PhD

From the Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, Md (C.A.P., T.M.); Department of Medicine, Division of Cardiology (C.A.P.), and Departments of Medicine and Epidemiology (N.R.P.), Johns Hopkins Medical Institutions, Baltimore, Md; Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.F.); Department of Biostatistics (E.S.O.), and Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Services (B.M.P.), University of Washington, Seattle; and Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pa (L.K.).

Correspondence to Dr Camille A. Pearte, Cardiovascular Clinical Research Center, VA-NYUSOM, 423 E 23rd St, 15 North, 15142N, New York, NY 10010. E-mail camille.pearte{at}med.nyu.edu

Received May 7, 2005; de novo received January 25, 2006; accepted February 24, 2006.

Background— Although >80% of annual coronary heart disease (CHD) deaths occur in adults aged >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 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 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.

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CLINICAL PERSPECTIVE

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