Early Aggressive Therapy Helps Elderly Patients With Elevated Troponin

Early aggressive therapy for elderly patients with non-ST-segment elevation acute coronary syndrome (ACS) significantly benefited those age 75 and older who had elevated troponin levels when compared with initial conservative treatment, according to a study published on Sept. 17 in the Journal of the American College of Cardiology: Cardiovascular Interventions.

The investigators found that 43 patients in the early aggressive therapy group (27.9 percent) experienced the primary endpoint of a composite of death, myocardial infarction, disabling stroke or repeat hospital stay for cardiovascular causes or severe bleeding within one year, versus 55 patients in the initially conservative treatment group (34.6 percent).

The randomized, controlled trial, known as the Italian Elderly ACS Trial, was conducted at medical centers in Italy and randomized 313 patients >75 years of age (mean 82 years) with non-ST-segment elevation acute coronary syndrome. Upon admission, patients received either early aggressive therapy or initially conservative therapy.

"This is a small, but very compelling study that helped investigators determine which group of older patients would benefit from aggressive treatment," said Daniel E. Forman, MD, FACC, chair of ACC's Geriatric Cardiology Section and associate professor of medicine at Harvard Medical School. "This trial flies in the face of the idea that 80-year-olds may be too old for aggressive therapy, and says that by being aggressive at times, we can help someone have a better life, even at 82 years old."

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Investigators also found that the primary endpoint was significantly reduced in patients with elevated troponin levels on admission, but not in patients with normal troponin levels (p = 0.03). "A lot of literature argues that troponin is a physiologic way of determining disease impact on the heart," added Forman. "It is more sensitive than EKG in determining when the heart has sustained direct injury, and is a more robust marker than symptoms in indicating a more aggressive strategy in older patients."

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