Temporal trends in management and outcomes of acute coronary syndrome in an aging population: a 10-year multicenter registry

Background

Management of acute coronary syndrome (ACS) has evolved substantially over the past decade, particularly with widespread adoption of radial access and contemporary mechanical circulatory support (MCS). Whether these changes have translated into sustained improvements in outcomes in an aging population remains uncertain.

Purpose

To determine whether temporal changes in invasive strategies and reperfusion practice were associated with changes in in-hospital mortality over a 10-year period in a large multicenter ACS registry (K-ACTIVE).

Methods

We analyzed consecutive ACS patients enrolled between 2015 and 2024 across 58 centers. Temporal trends in patient characteristics, reperfusion metrics, procedural strategies, and in-hospital outcomes were assessed using trend analyses.

Results

A total of 18,762 patients were included. Over time, patients became significantly older (mean age 68±13 vs. 71±13 years; p for trend <0.01), while the proportion of STEMI remained stable (~75%; p=0.38).

Radial access markedly increased from 53% to 86% (p for trend <0.01), and multivessel disease decreased (56% to 44%; p<0.01).

Door-to-device time remained stable (median 84 vs. 83 minutes), and the proportion achieving <90 minutes did not substantially improve (~45%; p<0.01), suggesting overall system maturity rather than further temporal shortening.

Use of IABP declined (18% to 13%), whereas Impella was introduced after 2020.

In-hospital mortality decreased from 9.4% in 2015 to 6.4% in 2016 and remained consistently around 6.5% thereafter (p for overall trend <0.01). When excluding 2015, mortality remained stable without evidence of temporal increase despite progressive aging.

Conclusion

In this large 58-center registry of 18,762 ACS patients, in-hospital mortality remained consistently low over the past decade despite progressive aging and stable reperfusion metrics. The evolution of invasive strategies—particularly widespread radial adoption—may have contributed to maintaining favorable outcomes in an increasingly complex ACS population.10 year