Acute coronary syndromes: an old age problem
Alexander D Simms1, Philip D Batin, John Kurian
1Centre for Epidemiology and Biostatistics, Level 8, Worsley Building, University of Leeds, Clarendon Way, West Yorkshire, Leeds, LS2 9JT, UK.
Insights
Older adults with acute coronary syndromes (ACS) face care inequalities. Improving management and ensuring clinical trials include the elderly can enhance outcomes for this high-risk population.
Area of Science:
- Cardiology
- Geriatric Medicine
- Public Health
Background:
- The global population is aging, leading to an increased incidence of acute coronary syndromes (ACS) in older individuals.
- Elderly patients with ACS represent a high-risk group who could potentially benefit more from evidence-based therapies compared to younger patients.
- Existing age-related disparities in ACS care persist, impacting treatment and outcomes.
Purpose of the Study:
- To highlight the challenges and inequalities in the management of acute coronary syndromes (ACS) in the elderly population.
- To identify factors contributing to delayed diagnosis and underestimation of mortality risk in older ACS patients.
- To advocate for improved research and clinical practices to optimize ACS care for the aging demographic.
Main Methods:
- Review of current literature and clinical observations regarding ACS management in the elderly.
- Analysis of factors contributing to age-related inequalities in diagnosis and treatment.
- Identification of gaps in evidence, particularly from randomized controlled trials, concerning older adults with comorbidities.
Main Results:
- Older adults often present with atypical ACS symptoms and delayed diagnoses due to less frequent use of diagnostic electrocardiograms.
- Mortality risk in the elderly is frequently underestimated due to inadequate consideration of frailty, comorbidities, and cognitive/functional impairments.
- Limited cardiology specialist input and a lack of age-representative clinical trial data hinder optimal evidence-based therapy selection for elderly ACS patients.
Conclusions:
- Substantial improvements are needed in the care of elderly patients with acute coronary syndromes (ACS) to address existing inequalities.
- Increased enrollment of older adults with comorbidities in randomized controlled trials is crucial for developing tailored management strategies.
- Advocating for better reporting of adverse events and risk-benefit assessments in the elderly will lead to improved ACS outcomes, though non-modifiable age-related risks remain.
Abstract:
The increasing population in older age will lead to greater numbers of them presenting with acute coronary syndromes (ACS). This has implications on global healthcare resources and necessitates better management and selection for evidenced-based therapies. The elderly are a high risk group with more significant treatment benefits than younger ACS. Nevertheless, age related inequalities in ACS care are recognised and persist. This discrepancy in care, to some extent, is explained by the higher frequency of atypical and delayed presentations in the elderly, and less diagnostic electrocardiograms at presentation, potentiating a delay in ACS diagnosis. Under estimation of mortality risk in the elderly due to limited consideration for physiological frailty, co-morbidity, cognitive/psychological impairment and physical disability, less input by cardiology specialists and lack of randomised, controlled trials data to guide management in the elderly may further confound the inequality of care. While these inequalities exist, there remains a substantial opportunity to improve age related ACS outcomes. The selection of elderly patients for specific therapies and medication regimens are unanswered. There is a growing need for randomised, controlled trial data to be more representative of the population and enroll those of advanced age with co-morbidity. A lack of reporting of adverse events, such as renal impairment post coronary angiography, in the elderly further limit risk benefit decisions. Substantial improvements in care of elderly ACS patients are required and should be advocated. Ultimately, these improvements are likely to lead to better outcomes post ACS. However, the improvement in outcome is not infinite and will be limited by non-modifiable factors of age-related risk.
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