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

Abstract

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.

Acute Coronary Syndrome in Older Adults: an Update from the 2022 Scientific Statement by the American Heart Association

“…The standard of care for detecting myocardial injury is high-sensitivity cardiac troponin I (hs-cTn). However, certain conditions, such as myocardial fibrosis or chronic kidney disease, can result in higher baseline values and a lower positive predictive value (1). Compared with the first scientific statement on Acute Coronary Care in the Elderly published in 2007, (5,6) the latest document reported that more randomized controlled trials (RCTs) have involved older adults (1).…”

“…However, certain conditions, such as myocardial fibrosis or chronic kidney disease, can result in higher baseline values and a lower positive predictive value (1). Compared with the first scientific statement on Acute Coronary Care in the Elderly published in 2007, (5,6) the latest document reported that more randomized controlled trials (RCTs) have involved older adults (1). Both the After Eighty (2016) (7) suggests considering a medication review and deprescribing, lifestyle modifications and cardiac rehabilitation, comorbidity management, psychosocial support, socioeconomic factors, and education of both patients and caregivers.…”

Antiplatelet treatment for older patients with ACS — a challenging issue

“…Patients with ≥ 75 years of age represent a large and significant proportion of those admitted for acute coronary syndromes (ACS) in our hospitals [1]. Older patients frequently present with peculiar features and comorbidities (complex coronary lesions, anaemia, chronic kidney dysfunction, peripheral vascular disease) associated with geriatric syndromes (frailty, disability, cognitive impairment) that are relevant determinants of patients health and outcomes [2]. Older adults have frequently low-grade inflammation ("inflammaging") which has been associated with the occurrence of frailty and with the development of the atherosclerotic process [2].…”

“…Older patients frequently present with peculiar features and comorbidities (complex coronary lesions, anaemia, chronic kidney dysfunction, peripheral vascular disease) associated with geriatric syndromes (frailty, disability, cognitive impairment) that are relevant determinants of patients health and outcomes [2]. Older adults have frequently low-grade inflammation ("inflammaging") which has been associated with the occurrence of frailty and with the development of the atherosclerotic process [2]. The prevalence of frailty increases as age advances and is more frequent among elderly women: it is present in more than 20% of patients with 80 to 84 years of age [2,3].…”

“…Older adults have frequently low-grade inflammation ("inflammaging") which has been associated with the occurrence of frailty and with the development of the atherosclerotic process [2]. The prevalence of frailty increases as age advances and is more frequent among elderly women: it is present in more than 20% of patients with 80 to 84 years of age [2,3]. Cognitive impairment is not infrequent among frail older patients and may deteriorate at the time of ACS presentation, due to the stress of the acute event, the unfamiliar environment and side effects of medications [2].…”