Is the contemporary care of the older persons with acute coronary syndrome evidence-based?

Mills, Greg B; Ratcovich, Hanna; Adams‐Hall, Jennifer; Beska, Benjamin; Kirkup, Emma; Raharjo, Daniell Edward; Veerasamy, Murugapathy; Wilkinson, Chris; Kunadian, Vijay

doi:10.1093/ehjopen/oeab044

Cited by 20 publications

(18 citation statements)

References 58 publications

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“…To date, of the 5 randomized clinical trials specifically investigating an invasive strategy in older patients with NSTEMI, 4 have found no benefit of invasive treatment on the primary end point compared with conservative management, [130][131][132][133] whereas the other showed that an invasive strategy reduced recurrent MI and urgent repeat revascularization (Table 3). 134,135 The Italian Elderly ACS trial randomly assigned patients ≥75 years of age with non-ST-segment-elevation ACS to early invasive versus initially conservative strategy. The trial did not report geriatric syndromes including frailty and multimorbidity.…”

Section: Non-st-segment-elevation Myocardial Infarctionmentioning

confidence: 99%

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Damluji¹,

Forman²,

Wang³

et al. 2023

Circulation

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Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.

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Section: Non-st-segment-elevation Myocardial Infarctionmentioning

confidence: 99%

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Damluji¹,

Forman²,

Wang³

et al. 2023

Circulation

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“…Open access multimorbidity that present with NSTE-ACS and receive an invasive management strategy. [10][11][12][13] ESC guidelines highlight this important gap in evidence. 6 As the population ages, the proportion of these older patients with multiple chronic conditions and ACS will continue to increase, and data are needed to inform decision-making and discussions with patients and their families.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

“…Multimorbidity has been shown to be associated with adverse outcomes in patients with NSTE-ACS up to 3 years 8 9. However, we lack data to inform the optimal management strategy and longer term prognosis of older adults with multimorbidity that present with NSTE-ACS and receive an invasive management strategy 10–13. ESC guidelines highlight this important gap in evidence 6.…”

Section: Introductionmentioning

confidence: 99%

Impact of multimorbidity on long-term outcomes in older adults with non-ST elevation acute coronary syndrome in the North East of England: a multi-centre cohort study of patients undergoing invasive care

et al. 2022

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ObjectivesOlder adults have a higher degree of multimorbidity, which may adversely affect longer term outcomes from non-ST elevation acute coronary syndrome (NSTE-ACS). We investigated the impact of multimorbidity on cardiovascular outcomes 5 years after invasive management of NSTE-ACS.DesignProspective cohort study.SettingMulticentre study conducted in the north of England.Participants298 patients aged ≥75 years with NSTE-ACS and referred for coronary angiography, with 264 (88.0%) completing 5-year follow-up.Main outcome measuresMultimorbidity was evaluated at baseline with the Charlson comorbidity index (CCI). The primary composite outcome was all-cause mortality, myocardial infarction, stroke, urgent repeat revascularisation or significant bleeding.ResultsMean age was 80.9 (±6.1) years. The cohort median CCI score was 5 (IQR 4–7). The primary composite outcome occurred in 48.1% at 5 years, at which time 31.0% of the cohort had died. Compared with those with few comorbidities (CCI score 3–5), a higher CCI score (≥6) was positively associated with the primary composite outcome (adjusted HR (aHR) 1.64 (95% CI 1.14 to 2.35), p=0.008 adjusted for age and sex), driven by an increased risk of death (aHR 2.20 (1.38 to 3.49), p=0.001). For each additional CCI comorbidity, on average, there was a 20% increased risk of the primary composite endpoint at 5 years (aHR 1.20 (1.09 to 1.33), p<0.001).ConclusionsIn older adults with NSTE-ACS referred for coronary angiography, the presence of multimorbidity is associated with an increased risk of long-term adverse cardiovascular events, driven by a higher risk of all-cause mortality.Trial registration numberNCT01933581; ClinicalTrials.gov.

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“… 16 , 27 While there is a clear need for individualized, patient-centred care for older patients with NSTEACS, there is a gap in the existing evidence to guide the optimal management in the context of frailty, including the benefit of a routinely applied invasive strategy. 28 , 29 The results of the ongoing British Heart Foundation Older Patients With Non-ST SEgmeNt elevatIOn myocaRdial Infarction Randomized Interventional TreAtment trail (SENIOR-RITA, n = 1600) will be valuable in evaluating the role of invasive management in older adults with NSTEACS in the context of concomitant frailty.…”

Section: Discussionmentioning

confidence: 99%

Five-year clinical outcomes in patients with frailty aged ≥75 years with non-ST elevation acute coronary syndrome undergoing invasive management

Ratcovich

Beska

Mills

et al. 2022

European Heart Journal Open

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Background Frailty is associated with adverse outcomes in older patients with acute coronary syndrome (ACS). The impact of frailty on long-term clinical outcomes following invasive management of non-ST elevation ACS (NSTEACS) is unknown. Methods The multi-centre ICON-1 prospective cohort study consisted of patients aged ≥75 years undergoing coronary angiography following NSTEACS. Patients were categorised by frailty assessed by Canadian Study of Health and Ageing Clinical Frailty Scale (CFS) and Fried criteria. The primary composite endpoint was all-cause mortality, unplanned revascularisation, myocardial infarction, stroke, and bleeding. Results Of 263 patients, 33 (12.5%) were frail, 152 (57.8%) were pre-frail and 78 (29.7%) were robust according to CFS. By Fried criteria, 70 patients (26.6%, mean age 82.1 years) were frail, 147 (55.9%, mean age 81.3 years) were pre-frail, and 46 (17.5%, mean age 79.9 years) were robust. The composite endpoint was more common at five years among patients with frailty according to CFS (frail: 22, 66.7%; pre-frail: 81, 53.3%; robust: 27, 34.6%, p = 0.003), with a similar trend when using Fried criteria (frail: 39, 55.7%; pre-frail: 72, 49.0%; robust: 16, 34.8%, p = 0.085). Frailty measured with both CFS, and Fried criteria was associated with the primary endpoint (Age and sex-adjusted hazard ratio [HR] compared to robust groups. CFS: 2.22, 95% Confidence Interval [CI] 1.23-4.02, p = 0.008; Fried: HR 1.81, 95% CI 1.00-3.27, p = 0.048). Conclusion In older patients who underwent angiography following NSTEACS, frailty is associated with an increased risk of the primary composite endpoint at five years.

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Is the contemporary care of the older persons with acute coronary syndrome evidence-based?

Cited by 20 publications

References 58 publications

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Impact of multimorbidity on long-term outcomes in older adults with non-ST elevation acute coronary syndrome in the North East of England: a multi-centre cohort study of patients undergoing invasive care

Five-year clinical outcomes in patients with frailty aged ≥75 years with non-ST elevation acute coronary syndrome undergoing invasive management

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