Acute Coronary Syndrome in an Older Adult with Recent or Ongoing Cancer Treatment: Patient Case(s)
Drs. Krishnaswami and Vetrovec have discussed the appropriateness of aggressive treatment of elderly patients who are potentially candidates for invasive management which might be quite appropriate in younger patients without major comorbidities. However, there are increasingly frequent patient presentations which raise very important concerns about the appropriateness of "usual invasive care." Dr. Vetrovec offered the first use for discussion to illustrate an example of such a clinical challenge. While the cases presented appear to represent reasonable life goal supported, successful outcomes, invasive strategies may not always be most appropriate, either because of the patient facility, other comorbidities, or not in concert with patient and or family goals/wishes. We also want to remind the audience that geriatric care should not be considered synonymous with palliative care. The case presentations below illustrate the issue, and the discussions that follow are thoughtful comments by experts regarding management decisions in complex social and medical cases.
*Mrs. Jones, a 78-year-old female, presented to an outside hospital with chest pain. She was subsequently diagnosed as troponin negative acute coronary syndrome (unstable angina). Upon questioning, she described chest pain limiting her daily activity for the past 2 months. At presentation her Canadian Cardiovascular Society grading of angina pectoris was Class III.
Past Medical History: History of lung cancer. Currently stated to be in remission. History of surgery, chemotherapy and radiation completed a year and a half prior to presentation.
Examination: Healthy appearing lady, mildly short of breath with walking who is alert with mild bilateral wheezes but otherwise unremarkable physical exam.
*Mr. Smith, a 79-year-old male with a history of coronary artery disease presented to the emergency department with minimal chest pain, no significant electrocardiogram (ECG) changes and was admitted with suspected non-ST-elevation myocardial infarction (NSTEMI) with a peak troponin of 16 ng/ml. During hospitalization he did not complain of any further chest pain.
Past medical history: Coronary artery bypass graft (CABG) x 3 vessel, prior NSTEMI, metastatic bladder cancer on immunotherapy with pembrolizumab.
Examination: Tired looking male, alert and oriented, responding normal. Unremarkable physical exam.
When reviewing the two cases, what would your next management plan be?