Differences in Characteristics and Clinical Outcomes According to Age in Patients Following High-Risk Myocardial Infarction: Insights from PARADISE-MI

The prevalence of coronary heart disease is increasing in an aging population. A better understanding of how risk profiles and outcomes differ by age may allow for targeted treatment and prevention strategies. PARADISE-MI randomized 5661 adults without prior heart failure (HF) to sacubitril/valsartan versus ramipril within 0.5 to 7 days of a MI complicated by pulmonary congestion and/or LVEF ≤40%. Associations between age and clinical outcomes were analyzed using Cox models, adjusted for potential confounders. Mean age was 63.7 ± 11.5 years. Patients aged ≥75 years (n = 1051, 18.6%) were more often women, had more atrial fibrillation and lower eGFR. They more commonly presented with non-ST-segment elevation MI and were less likely to receive primary reperfusion and guideline-based medical therapies. Age was associated with all-cause death (HR 1.54 per 10-year increase; 95% CI, 1.41 to 1.68) and was more strongly associated with non-CV death (HR 2.09; 95% CI, 1.70 to 2.56) than with CV death (HR 1.43; 95% CI, 1.29 to 1.57). Age was associated with incident HF (HR 1.37; 95% CI, 1.25 to 1.49) and stroke (HR 1.31; 95% CI, 1.11 to 1.54). These risk relationships were similar after multivariable adjustment. The treatment effect of sacubitril/valsartan versus ramipril was not significantly modified by age (p-interaction = 0.19) and tolerability did not differ by treatment arm. In conclusion, the heightened risk of death, HF and stroke after MI with advancing age was not explained by differences in clinical characteristics. Older patients may require closer surveillance and more guidelines-based therapies after MI to mitigate the elevated risk of death and HF.