Advanced age, antithrombotic strategy, and bleeding in non-ST-segment elevation acute coronary syndromes: results from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial

J Am Coll Cardiol. 2009 Mar 24;53(12):1021-30. doi: 10.1016/j.jacc.2008.12.021.


Objectives: This study sought to evaluate the impact of age on outcomes in patients with moderate- and high-risk non-ST-segment elevation acute coronary syndrome (NSTE-ACS) enrolled in the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial.

Background: Aging-associated changes in physiology and metabolism may alter the risk and benefit of therapeutic strategies from that observed in younger people.

Methods: We performed a pre-specified analysis of 30-day and 1-year outcomes in 4 age groups, overall and among those undergoing percutaneous coronary intervention (PCI).

Results: Of 13,819 patients in the ACUITY trial, 3,655 (26.4%) were <55 years of age, 3,940 (28.5%) were 55 to 64 years of age, 3,783 (27.4%) were 65 to 74 years of age, and 2,441 (17.7%) were > or =75 years of age. Older patients had more cardiovascular risk factors and had a higher acuity at presentation. Patients age > or =75 years treated with bivalirudin alone had similar ischemic outcomes, but significantly lower rates of bleeding compared with those treated with heparin and glycoprotein IIb/IIIa inhibitors overall and in the PCI subset. The number needed to treat with bivalirudin alone to avoid 1 major bleeding event was lower in this age group (23 overall and 16 for PCI-treated patients) than in any other.

Conclusions: Ischemic and bleeding complications after NSTE-ACS increase with age. Although ischemic event rates are not statistically different with either bivalirudin alone or a heparin plus glycoprotein IIb/IIIa inhibitor, bleeding complications are significantly less frequent with bivalirudin alone. Because of the substantial risk of bleeding in patients age > or =75 years, the number needed to treat to avoid 1 major bleeding event using bivalirudin alone was the lowest in the elderly group, especially among those undergoing PCI.

Trial registration: NCT00093158.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Acute Coronary Syndrome / complications*
  • Acute Coronary Syndrome / drug therapy
  • Acute Coronary Syndrome / surgery
  • Aged
  • Aging / physiology*
  • Angioplasty, Balloon, Coronary
  • Anticoagulants / adverse effects
  • Coronary Artery Bypass
  • Enoxaparin / adverse effects
  • Female
  • Fibrinolytic Agents / adverse effects*
  • Hemorrhage / chemically induced*
  • Heparin / adverse effects
  • Hirudins / adverse effects
  • Humans
  • Male
  • Middle Aged
  • Peptide Fragments / adverse effects
  • Platelet Glycoprotein GPIIb-IIIa Complex / antagonists & inhibitors
  • Recombinant Proteins / adverse effects
  • Thrombosis / prevention & control*
  • Treatment Outcome


  • Anticoagulants
  • Enoxaparin
  • Fibrinolytic Agents
  • Hirudins
  • Peptide Fragments
  • Platelet Glycoprotein GPIIb-IIIa Complex
  • Recombinant Proteins
  • Heparin
  • bivalirudin

Associated data