[The elderly with acute coronary syndrome: the higher the risk, the lesser the treatment]
Stefano Savonitto1, Paola Colombo, Irene Bossi
1Dipartimento Cardiovascolare A De Gasperis, Ospedale Niguarda Ca' Granda, Milano. stefano.savonitto@fastwebnet.it
Insights
Elderly patients with acute coronary syndrome benefit more from treatments like reperfusion therapy and percutaneous coronary intervention. Adjusting regimens can mitigate risks, improving outcomes in older adults.
Area of Science:
- Cardiology
- Geriatric Medicine
- Acute Coronary Syndromes
Background:
- Elderly patients (over 75) constitute a significant portion of acute coronary syndrome (ACS) admissions.
- Older adults present with higher risk factors and worse outcomes, including mortality and heart failure.
- Current treatment disparities exist, with less frequent administration of effective therapies, particularly reperfusion therapy, in the elderly.
Purpose of the Study:
- To re-evaluate treatment strategies for acute coronary syndrome in elderly patients.
- To address the underutilization of effective therapies in older adults based on outdated evidence.
- To highlight the benefits of modern interventional approaches in geriatric ACS populations.
Main Methods:
- Review of recent randomized studies comparing treatment effects in elderly versus younger ACS patients.
- Analysis of data from centers performing systematic coronary angiography regardless of patient age.
- Consideration of specific risk factors and comorbidities in elderly ACS patients.
Main Results:
- Recent randomized trials indicate greater treatment benefits, especially in terms of lives saved, for elderly ACS patients compared to younger cohorts.
- Systematic coronary angiography has demonstrated feasibility and efficacy in elderly patients, challenging previous assumptions.
- Severe comorbidities require specific consideration rather than being a blanket contraindication for intervention.
- Elderly patients face a higher risk of iatrogenic bleeding, necessitating tailored therapeutic regimens.
Conclusions:
- Evidence supports more aggressive and effective treatment of ACS in elderly patients.
- Interventional cardiology approaches are viable and beneficial in older adults.
- Personalized treatment adjustments are crucial to maximize benefits and minimize risks, particularly bleeding, in geriatric ACS management.
Abstract:
Patients older than 75 years represent about one third of those admitted to the Italian coronary care units due to an acute coronary syndrome, with a greater prevalence of the form without ST-segment elevation. Compared to younger patients, the elderly have higher risk characteristics and more adverse outcomes, particularly mortality and heart failure. Despite this, they receive less effective treatments, and especially less coronary reperfusion therapy. This attitude is only partially motivated by the fear of the potential adverse effects of antithrombotic and invasive treatments in the elderly, on the basis of misleading meta-analyses and observational studies. A more objective approach is taking fuel by recent randomized studies showing that the treatment effect is even greater in the elderly (particularly when evaluated in terms of "number of lives saved"), whereas the benefit is often hardly seen in the younger population. Also, the idea that the elderly may have little room for percutaneous coronary intervention has been progressively wiped away by the experience of those Centers that have started systematic coronary angiography regardless of the patients' age. The presence of severe copathologies has been often considered to limit intervention in the elderly. This real difficulty (although more typical of the seventh and eighth decade than at older age) should be rather considered specifically and not as a mere consequence of age. The elderly patient is at higher risk of iatrogenic bleeding: therapeutic regimens should be adjusted specifically in order to reduce this untoward effect of effective treatments.
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