Management of Acute Coronary Syndromes in Older Adults

Authors:
Morici N, De Servi S, De Luca L, et al.
Citation:
Management of Acute Coronary Syndromes in Older Adults. Eur Heart J 2022;43:1542-1553.

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. The current review provides evidence-based recommendations for management of ACS in older adults.
  2. The effect of ageing on the cardiovascular system includes increased inflammation (decreased nitric oxide), increased blood pressure (increased arterial stiffness), vascular dysfunction, and increased heart failure (cardiac remodeling, diastolic dysfunction).
  3. Older patients presenting with ACS have unique features that bear consideration specifically related to clinical presentation (symptoms, multiple comorbidities, frailty, cognitive), risk stratification (bleeding risk, renal function), and treatment options (risks and benefits of an invasive approach).
  4. Women who are older at the time of ACS presentation remain at increased risk of mortality compared to men even after adjusting for differences in comorbidities.
  5. Though individualized risk assessment should be performed, invasive management is preferred regardless of age, sex, or type of ACS.
  6. Among older patients with acute myocardial infarction and shock, a culprit-only percutaneous coronary intervention (PCI) approach should be considered over multivessel PCI.
  7. Older age represents patients at higher risk of bleeding, and strategies including radial access, use of proton pump inhibitors, and bleeding risk scores should be used to minimize bleeding risk.
  8. Use of potent systemic anticoagulation and antiplatelet regimens in older adults with ACS comes with increased bleeding risk without improvement in mortality.
  9. Discharge from the hospital represents an opportunity to screen at-risk older patients for valvular disease, ensure minimization of drug interactions, and appropriate referral for outpatient rehabilitation.
  10. Older ACS patients who are frail and those with cognitive impairment are challenging subsets of patients who may need an individualized and holistic approach to management.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Anticoagulation Management and ACS, Acute Heart Failure, Interventions and ACS, Interventions and Structural Heart Disease

Keywords: Acute Coronary Syndrome, Aged, Anticoagulants, Blood Pressure, Cognition, Frail Elderly, Frailty, Geriatrics, Heart Failure, Heart Valve Diseases, Hemorrhage, Inflammation, Myocardial Infarction, Patient Discharge, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Proton Pump Inhibitors, Risk Assessment, Risk Factors, Secondary Prevention, Vascular Stiffness, Ventricular Remodeling


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