Poll Results: Older Adult Presenting with an Acute Coronary Syndrome
Mr. B is an 82-year-old Caucasian male presenting to the emergency department with retrosternal chest pain. His medical history can be found here.
We created a poll with two questions to stimulate further thoughts on pertinent issues in geriatric cardiology. The results of the poll are below.
For the first question, 37% voted for cardiac comorbidities and tests and 31% voted for a focus on geriatric conditions as the MOST important factor prior to making therapeutic decisions. A majority (68%) of individuals attempt to gather geriatric-specific conditions often or almost always prior to discussing therapeutic options with older adults presenting with an acute coronary syndrome (ACS).
It is important to recognize that older adults have often been excluded from cardiovascular clinical trials - specifically those living in nursing homes. When they have been included, they generally tend not to be representative of real-life patients (i.e., those who have a higher burden of multimorbidity, frailty, polypharmacy, and/or have associated decreased physical and cognitive function). Moreover, it is important to recognize that nursing home residence is a surrogate marker for functional status and a factor that is likely to influence life goals, priorities and response to invasive treatment.
The case pushes the reader to address the importance of combining the geriatric (patient-centered) and cardiovascular (therapy-centered) mindset1 to optimize cardiovascular care that can only result with creating greater evidence from randomized clinical trials in this area.
One study conducted in Norway, the After Eighty trial2 recruited patients who were ≥80-years presenting with an ACS (other than a ST-elevation myocardial infarction) and demonstrated that an invasive strategy was superior to a conservative strategy in the reduction of composite major adverse cardiovascular events. However, this effect was diminished with increasing age and fortunately did not differ in the incidence of bleeding complications. Furthermore, it is important to recognize that this trial did not gather information on patient-centered outcomes and the associated treatment burden that patients are willing to undertake.
The education goal of the case, poll and take-home points were to increase awareness of the necessity to gather geriatric-specific conditions when older adults present with ACS. To further expand on this topic, a summary of an observational study from the Journal of the American Geriatrics Society is reviewed and geriatric cardiology take home points are provided.
- Krishnaswami A, Maurer MS, Alexander KP. Contextualizing myocardial infarction: comorbidities and priorities in older adults. Am J Med 2017;130:1144-47.
- Tegn N, Abdelnoor M, Aaberge L, et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial. Lancet 2016;387:1057-65.
Keywords: Geriatrics, Acute Coronary Syndrome, Polypharmacy, Frail Elderly, ST Elevation Myocardial Infarction, Chest Pain, Cognition, Emergency Service, Hospital, Patient-Centered Care, Biomarkers, Nursing Homes, Homes for the Aged, Morbidity, Comorbidity, Aged, 80 and over
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