[Therapeutic strategies in elderly patients with acute coronary syndromes]

Because of the aging of the population, the proportion of elderly patients admitted to the coronary care unit for an acute coronary syndrome (ACS) is increasing. Until a decade ago, treatment of elderly patients was based on poor scientific evidence, as older patients were commonly excluded from randomized controlled trials. In the last years, real-world registries and randomized controlled trials specifically addressing the older population have been published and provided clear evidence. Primary percutaneous angioplasty has become the standard of care for the treatment of ST-elevation myocardial infarction also in the elderly population, whereas the Italian Elderly ACS and the After Eighty randomized trials have demonstrated the superiority of an invasive strategy over an initial conservative strategy also in elderly patients affected by non-ST-elevation myocardial infarction. Moreover, real-world registries have shown that an increased use of early revascularization was associated with a progressive reduction in mortality after ACS: these findings have been confirmed also in a clinical context characterized by high mortality rates such as that of cardiogenic shock. As 80% of deaths after an ACS have been shown to be due to cardiovascular causes also in the elderly, the focus has been shifted to secondary prevention. Data regarding the use of both ticagrelor or low-dose prasugrel, as compared to clopidogrel, showed that a reduction of ischemic events was counterbalanced by an increase in bleeding events. In perspective, it might be interesting to explore the superiority of a strategy that limits the duration of dual antiplatelet therapy to a short period after an ACS (when the ischemic event rate is higher) in elderly patients, and to explore other endpoints such as mid-term quality of life outcome after ACS in elderly patients.