Acute coronary syndromes in the elderly
Zenon S Kyriakides1, Spyros Kourouklis, Konstantinos Kontaras
12nd Department of Cardiology, Hellenic Red Cross Hospital, Athens, Greece. zskyr@otenet.gr
Insights
Elderly patients with acute coronary syndromes (ACS) often have worse outcomes and require tailored treatments. Invasive strategies like angioplasty are generally preferred over fibrinolysis for ST-segment elevation myocardial infarction (STEMI) in this population.
Area of Science:
- Cardiology
- Geriatric Medicine
- Internal Medicine
Background:
- Elderly patients represent a growing demographic for acute coronary syndromes (ACS).
- This population often presents with complex comorbidities, leading to poorer outcomes compared to younger patients.
- Elderly individuals are less likely to receive revascularization and evidence-based medications.
Purpose of the Study:
- To review the specific challenges and optimal management strategies for acute coronary syndromes (ACS) in the elderly.
- To highlight the importance of considering physiological age over chronological age in treatment decisions for older ACS patients.
Main Methods:
- Review of existing literature and clinical trial data concerning ACS management in elderly populations.
- Analysis of treatment efficacy and safety profiles of various interventions, including angioplasty, fibrinolysis, and stenting.
Main Results:
- Non-ST-segment elevation myocardial infarction (NSTEMI) is common and associated with high mortality in the elderly.
- Early invasive treatment is recommended for elderly patients with NSTEMI and unstable angina.
- Primary angioplasty appears more effective than fibrinolysis for ST-segment elevation myocardial infarction (STEMI) in the elderly, with drug-eluting stents showing greater benefit and cost-effectiveness.
- Low-molecular-weight heparin may be superior to unfractionated heparin post-fibrinolysis, but carries a higher bleeding risk, especially in older women.
Conclusions:
- Treatment decisions for elderly ACS patients should prioritize physiological age and comorbidities over chronological age.
- Angioplasty should be preferred for STEMI in the elderly when feasible, though further trials are needed.
- Careful consideration of bleeding risks is crucial when selecting antithrombotic therapies in this demographic.
Abstract:
The elderly constitute an increasingly important sector of patients with acute coronary syndromes (ACS), although they have been under-represented in many therapeutic trials. Elderly patients with ACS usually have more complex co-morbidities and worse outcomes than their younger counterparts, and they are less likely to undergo revascularisation or to receive short- and long-term evidence-based medications. The most common ACS in the elderly is non-ST-segment elevation myocardial infarction (STEMI), which is associated with high mortality. For this reason, elderly patients with non-STEMI and unstable angina should be treated invasively early in the course of the episode. In elderly patients with STEMI, primary angioplasty seems to be more effective than fibrinolysis, and in patients aged >85 years a more conservative approach to fibrinolysis is also warranted because of the higher risk for cerebral haemorrhage. Therefore, angioplasty should be preferred when feasible, although more trials are needed before this strategy can definitely be documented as the preferred option. Drug-eluting stents afford greater benefit than bare metal stents in elderly patients and are more cost effective. After fibrinolysis, low-molecular-weight heparin appears to be superior to unfractionated heparin in elderly patients with STEMI but major bleeding and intracranial haemorrhages occur more frequently, especially in women aged >75 years. It is very important to understand that the elderly with ACS constitute a subgroup of atherosclerotic patients for whom decision making must be guided by the patients''physiological age' (determined by their physical condition and other co-morbidities) and not strictly by their 'chronological age'.
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