Special issues when caring for the older person with acute coronary syndromes
Rahman Shah1, JoAnne Micale Foody
1Yale University School of Medicine, PO Box 208017, 333 Cedar Street, Room 315B FMP, New Haven, CT 06520-8025, USA. joanne.foody@yale.edu
Insights
Older adults, despite being high-risk for acute coronary syndromes (ACS), often receive underused evidence-based treatments. Age should not preclude optimal reperfusion strategies and guideline-directed medical therapy for ACS in this population.
Area of Science:
- Cardiology
- Geriatric Medicine
- Clinical Practice Guidelines
Background:
- Persons aged 75+ represent 6% of the US population but over a third of acute coronary syndrome (ACS) cases.
- Limited enrollment of older adults in clinical trials restricts evidence-based treatment guidelines for this demographic.
- Older patients with ACS present unique challenges due to comorbidities and altered drug metabolism.
Purpose of the Study:
- To review current evidence and clinical practice for managing acute coronary syndromes (ACS) in patients aged 75 years or older.
- To emphasize the importance of not withholding guideline-directed therapies from elderly ACS patients based solely on age.
- To highlight the underutilization of evidence-based treatments in this high-risk population and advocate for improved care.
Main Methods:
- Review of existing literature and clinical trial data concerning ACS management in elderly populations.
- Analysis of pharmacologic treatments including aspirin, beta-blockers, nitrates, clopidogrel, heparin, statins, and ACE inhibitors, with emphasis on dose titration and toxicity monitoring.
- Evaluation of reperfusion strategies, including primary angioplasty and thrombolytic therapy, as well as the role of glycoprotein IIb/IIIa inhibitors in older ACS patients.
Main Results:
- Standard ACS medications are effective in older adults when initiated at lower doses with careful monitoring for toxicity.
- Reperfusion therapy, including primary angioplasty and selected thrombolytic therapy, is beneficial and should not be withheld due to age.
- Glycoprotein IIb/IIIa inhibitors may offer benefits in select elderly patients, but bleeding risks require careful consideration.
Conclusions:
- Evidence-based therapies for acute coronary syndromes are underused in patients aged 75 and older.
- Age alone should not be a barrier to optimal reperfusion strategies and guideline-directed medical therapy for ACS.
- Enhanced efforts are crucial to improve the quality of care and treatment adherence for elderly ACS patients, a high-risk cohort.
Abstract:
Persons 75 years of age or older constitute 6% of the US population but account for more than one third of those with acute coronary syndromes (ACS). Unfortunately, most randomized clinical trials have enrolled few older persons, and, as a result, few data are available to guide clinical practice. As in younger patients, aspirin, beta-blockers, nitrates, clopidogrel, heparin, statins, and angiotensin-converting enzyme inhibitors are useful, beginning with lower doses and carefully observing the patient for symptoms of toxicity. Similarly, older patients should not be denied the benefit of reperfusion therapy and early invasive strategy because of their age. Although primary angioplasty is an optimal reperfusion strategy, thrombolytic therapy is a beneficial alternative in carefully selected older patients. Although glycoprotein IIb/IIIa inhibitors appear to be beneficial in select cases, bleeding concerns exist. Despite a growing body of evidence in support of aggressive ACS care in older persons, evidence-based therapy is underused in older patients. Continued efforts are required to improve the quality of care to this high-risk cohort of ACS patients.
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