The following are key points to remember from this state-of-the-art review on management of acute coronary syndromes (ACS) in older adults:

1. While older adults account for 6% of the worldwide population, they account for two-thirds of all patients with cardiovascular disease (CVD). In fact, >85% of octogenarians live with some form of CVD.
2. CV ageing is characterized by endothelial dysfunction and dysregulated inflammation, which increases the risk of thromboembolic events. At the same time, ageing is an important risk factor for bleeding.
3. While older patients are at increased risk of bleeding with fibrinolysis, prospective, observational, and randomized trial data have demonstrated overall efficacy and safety with primary percutaneous coronary intervention (PCI) for older adults with ACS.
4. The European Society of Cardiology (ESC) 2017 guideline for ST-segment elevation myocardial infarction (STEMI) states that there is no upper age limit with respect to reperfusion, especially with primary PCI.
5. Recent ESC guidelines for non–STEMI (NSTEMI) recommend that for older people, clinicians apply the same diagnostic and interventional strategies that are used for younger patients.
6. Among older patients with multivessel coronary disease who were enrolled in the CULPRIT-SHOCK trial, there was no difference in efficacy based on age. Therefore, culprit lesion only revascularization can be recommended in older adults with acute MI-related cardiogenic shock.
7. Many older patients with ACS have multiple complex comorbidities, including chronic kidney disease, myocardial fibrosis and hypertrophy, valvular heart disease, and frailty.
8. Use of P2Y12 receptor inhibitor therapy must be adapted for older adults. The Food and Drug Administration recommends avoiding the use of prasugrel for older adults (age >75 years), while the European Medicines Agency recommends use of a lower dose (prasugrel 5 mg daily) in older adults. At the same time, the mortality benefit of ticagrelor over clopidogrel was consistent in older and younger adults with ACS, albeit at the increased risk of intracranial hemorrhage.
9. In general, the majority of older adults with ACS should receive shorter durations of dual antiplatelet therapy (often 3-6 months) with a preferable use of clopidogrel with low-dose aspirin.
10. For older adults with comorbid atrial fibrillation and ACS, use of dual therapy (oral anticoagulant plus single antiplatelet therapy) is generally safer than use of triple therapy (oral anticoagulant plus dual antiplatelet therapy). After completion of the antiplatelet therapy, life-long direct oral anticoagulant monotherapy is generally recommended.
11. In general, recommended medical therapy for patients with ACS (e.g., beta-blocker and angiotensin-converting enzyme inhibitor if systolic dysfunction) are similar for older and younger adults.
12. The use of potent statin therapy to reduce low-density lipoprotein is recommended for older adults based on a large meta-analysis showing significant reductions in major vascular events, including CV, MI, stroke, and coronary revascularization.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Valvular Heart Disease, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Cardiac Surgery and VHD, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Interventions and ACS, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Chronic Angina

Keywords: Acute Coronary Syndrome, Aged, 80 and over, Anticoagulants, Aspirin, Atrial Fibrillation, Coronary Disease, Geriatrics, Fibrinolysis, Fibrosis, Frail Elderly, Hemorrhage, Heart Valve Diseases, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertrophy, Inflammation, Intracranial Hemorrhages, Lipoproteins, LDL, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Primary Prevention, Renal Insufficiency, Chronic, Reperfusion, Risk Factors, Shock, Cardiogenic, ST Elevation Myocardial Infarction, Stroke, Vascular Diseases

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