Antiplatelet therapy in elderly patients with acute coronary syndrome: Between scientific evidence and future
Francesco Barillà1, Concetta Torromeo, Riccardo Iorio
1"Sapienza" University of Rome, Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences. francesco.barilla@uniroma1.it.
Insights
Dual antiplatelet therapy (DAPT) reduces cardiovascular events after acute coronary syndrome (ACS). For elderly patients, DAPT duration must balance bleeding and clotting risks, often requiring less than 12 months based on individual risk assessment.
Area of Science:
- Cardiology
- Geriatric Medicine
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) is crucial for managing acute coronary syndrome (ACS).
- Elderly patients face increased bleeding risks with DAPT compared to younger individuals.
- Clinical trials often underrepresent elderly populations, leading to treatment protocols based on younger patient data.
Purpose of the Study:
- To review DAPT strategies in elderly patients (≥ 75 years) post-ACS.
- To emphasize risk stratification for tailoring DAPT type and duration.
- To guide clinical decisions on DAPT modification based on patient-specific factors.
Main Methods:
- Review of current guidelines and clinical trial data concerning DAPT in ACS.
- Analysis of factors influencing thrombotic and hemorrhagic risks in elderly patients.
- Discussion of individualized DAPT management strategies.
Main Results:
- Standard DAPT (aspirin plus P2Y12 inhibitor) for 12 months is often recommended post-ACS, even for the elderly.
- Elderly patients require careful consideration of bleeding risk, necessitating personalized DAPT duration.
- DAPT should be adaptable, allowing modifications based on clinical status and surgical needs.
Conclusions:
- DAPT in elderly ACS patients necessitates dynamic management, not a one-size-fits-all approach.
- Patients with moderate-high or very high bleeding risk may require DAPT shorter than 12 months.
- Prolonged DAPT beyond 12 months is reserved for select elderly patients after thorough ischemic/hemorrhagic risk assessment.
Abstract:
Dual antiplatelet therapy (DAPT) is an important strategy for reducing cardiovascular events (CV) after an acute coronary syndrome (ACS). Elderly patients undergoing DAPT have a higher risk of bleeding than younger patients for a variety of reasons. Stratification of thrombotic/hemorrhagic risk is mandatory in order to decide on the type and duration of DAPT. The percentage of patients ≥ 75 years represented in clinical trials is not large, so very often elderly people are prescribed treatment protocols only experimented on younger patients with a lower hemorrhagic risk. However, even in patients aged ≥ 75 treated with invasive or conservative therapy, after an ACS, a DAPT with aspirin 80-100 mg/day plus a P2Y12 receptor inhibitor for 12 months is recommended. In elderly patients, DAPT should be considered a dynamic process that can be modified over time based on the patient's clinical conditions, or any other necessities (non-procrastinating surgical interventions, comorbid-like effects that can increase hemorrhagic risk). In patients with moderate-high or very high hemorrhagic risk, DAPT treatment should last less than 12 months. A prolongation of DAPT beyond 12 months in this setting is limited to a very low percentage of patients, after careful assessment of ischemic/hemorrhagic profile.
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