Acute Coronary Care in the Elderly, Part I

Abstract

Background— Age is an important determinant of outcomes for patients with acute coronary syndromes (ACS); however, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients with ACS who would stand to benefit. Reasons include limited trial data to guide the care of older adults and uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age or complex health status. Methods and Results— This 2-part American Heart Association scientific statement summarizes evidence on patient heterogeneity, clinical presentation, and treatment of non–ST-elevation ACS in relation to age (<65, 65 to 74, 75 to 84, and ≥85 years). In addition, we review methodological issues that influence the acquisition and application of evidence to the elderly patients treated in community practice. A writing group combining international cardiovascular and geriatric perspectives convened to summarize available data from trials (5 combined Virtual Coordinating Center for Global Collaborative Cardiovascular Research [VIGOUR] trials) and 3 registries (Global Registry of Acute Coronary Events, National Registry of Myocardial Infarction, and the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines national quality improvement initiative [CRUSADE]) to provide a conceptual framework for future work in the care of the elderly with acute cardiac disease. Treatment for non–ST-segment–elevation ACS (Part I) and ST-segment–elevation myocardial infarction (Part II) are reviewed. In addition, ethical considerations pertaining to acute care and secondary prevention are considered (Part II). The primary goal is to identify the areas in which sufficient evidence is available to guide practice, as well as to determine areas that warrant further study. Although treatment-related benefits should rise in an elderly population with high disease risk, data to assess these benefits are limited, outcomes of importance vary, and heterogeneity among the elderly increases treatment-related risks. Although a uniform approach to care in the oldest of the old is unlikely, understanding the major contributors to benefits and risks from treatment will advance the ability to apply guideline-based care in this subset of patients. Conclusions— Although a few recent trials have described treatment effects in older patients, others continue to exclude patients on the basis of age. Going forward, prospective trials should enroll elderly subjects proportionate to their prevalence among the treated population to define risk and benefit. Findings from age subgroup analyses should be reported in a consistent manner across trials, including absolute and relative risks for efficacy and safety. Outcomes of particular relevance to the elderly, such as quality of life, physical function, and independence, should also be considered. Creatinine clearance should be calculated for every elderly patient to enable appropriate dosing. In addition, physicians need an understanding of conditions unique to older patients (eg, frailty, cognitive impairment) that influence treatment goals and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed in the health context of the elderly patient with ACS.

Long‐Term Mortality of Older Patients With Acute Myocardial Infarction Treated in US Clinical Practice

“…Prior studies demonstrated suboptimal adherence to statins among older patients with MI, and low medication adherence was associated with a higher risk of major cardiovascular events 17, 18. The high observed death rate in older patients may reflect the influence of multiple comorbidities and frailty on post‐MI recovery 1. Our study underscores the large comorbidity burden among older MI patients; 77% had hypertension, 35% had diabetes mellitus, 17% had renal insufficiency, and 13% had prior stroke.…”

“…Novel medication approaches to secondary prevention may be of particular interest to older patients with MI. Furthermore, older patients with MI are often excluded or underrepresented in clinical trials 1. The high observed mortality underscores the need for older patients with MI to be represented in these trials, and also that trials involving this high‐risk group can be informative with relatively small sample sizes.…”

“…By 2030, 71 million adults will be age 65 years or older and will comprise 20% of the total population 1. Coronary disease disproportionately affects older adults; however, long‐term outcomes of older patients after myocardial infarction (MI) are not well studied, as these patients are often under‐represented in randomized clinical trials and prospective longitudinal studies rarely follow patients beyond the first few years after their index event 1, 2, 3, 4.…”

“…Coronary disease disproportionately affects older adults; however, long‐term outcomes of older patients after myocardial infarction (MI) are not well studied, as these patients are often under‐represented in randomized clinical trials and prospective longitudinal studies rarely follow patients beyond the first few years after their index event 1, 2, 3, 4. Knowledge of long‐term prognosis can aid in treatment decisions for older patients with MI.…”

Age and clinical outcomes in patients presenting with acute coronary syndromes

“…22 Although elderly patients were more likely to have worse clinical profile; they were less likely to receive guideline-recommended medical and interventional therapies. Previous studies 13,19,23e25 reported similar age-dependent results.…”