Management of acute coronary syndrome in special subgroups: female, older, diabetic and Indigenous patients

Abstract

Summary While the evidence base for management of acute coronary syndrome (ACS) is extensive, some subgroups have been underrepresented or excluded from relevant clinical trials. These subgroups — such as women, older people, diabetic patients and Indigenous Australians — present clinical challenges for which there is limited evidence to guide optimal therapy. Women may have a different pattern of presentation, with potential for delays in diagnosis and worse outcomes in ST‐elevation myocardial infarction, but there is no evidence that treatments affect them differently from men. Older people suffer from a high‐risk, low‐treatment paradox. This may be due to under‐appreciation of the benefits of treatments for older people, or to good clinical judgement in avoiding harm from worsening age‐related comorbidities. Patients with diabetes have a high risk of ACS and suffer worse outcomes. Moderate glycaemic control with close monitoring and avoidance of hypoglycaemia are recommended. Coronary artery bypass grafting is preferred to percutaneous coronary intervention for patients with diabetes and multivessel disease, although the latter is reasonable in single‐vessel disease. Indigenous patients have a high prevalence of coronary disease, with more frequent coronary events at a young age, a heavy load of risk factors and poor outcomes after ACS. The complex sociocultural barriers to treatment are yet to be addressed adequately.

Use of Copeptin in Differential Diagnosis of (Acs) for Males vs Females in Emergency Departmen

“…Secondary causes of myocardial injury and infarction were more common in women than in men (Maas and Appelman 2010). Women are at higher short term and long term risk of death after acute coronary syndrome (McQuillan et al, 2014). In our study, women with small undisclosed increases in troponin concentrations that were only discernible using the high sensitivity assay with sex specific diagnostic thresholds, were less likely to receive evidence based treatments and had the highest rates of reinfarction and death at 12 months.…”

Early repolarization patterns associated with increased arrhythmic risk are common in young non-Caucasian Australian males and not influenced by athletic status

“…The association between increased-risk ER and ventricular tachyarrhythmias in the context of myocardial ischaemia is of most immediate relevance to populations with a pre-existing risk for cardiac disease and SCD. In Australia, the incidence of AMI in indigenous males aged 25-54 is estimated to be 6-fold higher, and 48-hour mortality following AMI around 10-fold higher than that of non-indigenous males (35).…”