Management of Acute Coronary Syndrome in Older Adults: Key Points

Damluji AA, Forman DE, Wang TY, et al., on behalf of the American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology; Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular Radiology and Intervention.
Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation 2022;Dec 12:[Epub ahead of print].

The following are key points to remember from this American Heart Association scientific statement on the management of acute coronary syndrome in the older adult population:

  1. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by geriatric cardiovascular and noncardiovascular comorbid conditions, contribute to the worse acute coronary syndrome (ACS) prognosis observed in older individuals.
  2. Consideration of frailty, multimorbidity, cognitive impairment, functional decline, nutritional deficiencies, and polypharmacy is necessary when managing older patients with ACS.
  3. A holistic, patient-centered approach that specifically considers age-related complexities (goals of care, patient preferences, functional status) among older adults is needed to not only optimize clinical outcomes but also quality of life.
  4. Older adults with ACS are more likely to have atypical symptoms at presentation (shortness of breath, syncope, sudden confusion) and cardiac troponin assays have lower positive predictive value in older adults.
  5. Immediate myocardial reperfusion by primary percutaneous coronary intervention (PCI) is beneficial in older patients with ST-segment elevation myocardial infarction. But for patients with cardiogenic shock and cardiac arrest, careful selection is warranted given their high inherent risk for adverse outcomes and futility.
  6. Due to significantly increased bleeding risk among older adults, bleeding reducing strategies such as use of radial access, appropriately dosed anticoagulants, and use of clopidogrel over other P2Y12 inhibitors is recommended. Duration of triple therapy should be minimized among patients with chronic atrial fibrillation and ACS needing PCI.
  7. Among older adults with left main or multivessel coronary disease, coronary artery bypass graft surgery with the goal of complete revascularization has shown survival benefits, but shared decision-making with patient and family is critical, particularly among very old adults. The use of percutaneous revascularization with medical therapy or medical therapy alone are also reasonable options if symptom control is a primary patient-centered goal.
  8. For older patients at a high risk of death and adverse outcomes, a major challenge is to identify futility before rather than after revascularization, but establishing goals of care in older patients from the outset may help avoid unwanted or futile intervention. Research is needed to better determine the utility and timing of palliative care interventions in older patients with ACS and how to best integrate palliative care precepts into standard post-ACS care.
  9. Transitions of care are high-risk times for older adults after ACS; multidisciplinary coordination of care is integral to a successful discharge/transitional care plan for older patients with ACS. Detailed medication review and reconciliation are important to avoid polypharmacy and maintain access to correct medications.
  10. Cardiac rehabilitation provides an opportunity for strength training, nutritional emphasis, and other strategies to mitigate frailty effects and improve patient-centered outcomes.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Interventions and ACS, Interventions and Vascular Medicine, Chronic Angina

Keywords: Acute Coronary Syndrome, Anticoagulants, Atrial Fibrillation, Coronary Disease, Dyspnea, Frailty, Geriatrics, Heart Arrest, Hemorrhage, Medical Futility, Multimorbidity, Myocardial Reperfusion, Myocardial Revascularization, Palliative Care, Patient Discharge, Percutaneous Coronary Intervention, Plaque, Atherosclerotic, Polypharmacy, Quality of Life, Shock, Cardiogenic, ST Elevation Myocardial Infarction, Syncope, Troponin

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