Therapeutic management and one-year outcomes in elderly patients with acute coronary syndrome

Abstract

BackgroundElderly represents a subgroup of high-risk ACS patients due to their advanced age and other comorbidities. Unfortunately, they are also often under-represented in many studies and clinical trials. Furthermore, cardiologists commonly find difficulties in the choice of the antiplatelet treatment and even on whether invasive revascularization should be used. In this study, the management of elderly ACS patients regarding antiplatelet therapy and revascularization procedures will be analyzed.Methods1717 ACS patients were consecutively included in this study from 3 tertiary Hospitals in the Southeast of Spain. Of them, 529 (30.8%) were ≥ 75 years. They were mainly male (60.7%) with a mean age of 81.4±4.7 years. Clinical characteristics, treatment received (antiaplatelet therapy, revascularization) and outcome were analyzed.ResultsRegression analysis showed that being ≥ 75 years is independently associated with neither performing catheterization (79.6% vs 97.1%), nor revascularization (51.8% vs 72.5%), being the medical conservative treatment the election in these elderly patients (40.6% vs 18.9%) (p < 0.001 for all). Furthermore, ticagrelor prescription were significantly decreased in older patients (11.5% vs 19.6%; p < 0.001). Regarding patients outcome after one-year of follow-up, being ≥ 75 years was associated with death, major adverse cardiac events (MACE) and major bleeding (all of them p < 0.001). Importantly, nor performing catheterization was independently associated with MACE and death in Cox multivariate analysis in elderly patients.ConclusionsElderly patients with ACS are undertreated both invasively and pharmacologically, and this fact might be associated with the observed worse outcomes.

Non-ST elevation acute coronary syndromes; clinical landscape, management strategy and in-hospital outcomes: an age perspective

“…Impaired left ventricular function and higher incidence of acute heart failure justify the higher rate of using loop diuretic and mineralocorticoid receptor antagonist in the older group. Older patients were less treated invasively; these results were supported by prior studies including GRACE and ROSAI-2 registries [ 13 , 24 – 27 ]. Many factors contribute to less referral for catheterization in older patients with NSTE-ACS like associated comorbidities, especially anaemia and CKD, higher rate of bleeding complications and the more presentation with haemodynamic instability in this population [ 13 ].…”

“…Older patients were less treated invasively; these results were supported by prior studies including GRACE and ROSAI-2 registries [ 13 , 24 – 27 ]. Many factors contribute to less referral for catheterization in older patients with NSTE-ACS like associated comorbidities, especially anaemia and CKD, higher rate of bleeding complications and the more presentation with haemodynamic instability in this population [ 13 ]. Furthermore, there are contradictory results with respect to prognostic benefit of routine invasive strategy in the elderly with NSTE-ACS, MOSCA and Italian Elderly ACS trials [ 28 , 29 ], which are two randomized controlled trials that showed no difference between invasive and conservative strategies in the elderly with NSTE-ACS in terms of recurrent MI, cardiovascular rehospitalization and mortality.…”

“…Despite guideline recommendations [ 19 – 21 ] and prognostic benefit, there is a trend to use statin more in the younger group, consistent with earlier studies [ 12 , 18 ]. While aging did not impact their prescription, B-blockers and ACEI/ARBs were used at a lower rate in the current study compared with earlier researches [ 12 , 13 ]; B-blockers and ACEI/ARBs were expected to be used more significantly compared with the younger group in our study as the recruited elderly patients had more indications to use ACEI/ARBs in terms of being more diabetic, hypertensive with higher systolic blood pressure, have lower ejection fraction and remarkably developed heart failure during hospitalization more than their younger counterparts, yet the older study group had higher renal indices which might explain the relative under-prescription of ACEI/ARBs fearing from developing hyperkalaemia, in addition to potential complications of postural hypotension and increased risk of falls; however, such adverse effects can be overcome by proper monitoring of renal function and gradual up titration of doses [ 15 , 22 ]. In the same line, fearing from adverse effects of B-blockers like fatigue, dizziness, or physicians’ perception of less efficacy in the elderly due to decrease B-receptors [ 13 , 23 ], all can lead to under use of B-blockers in the older group in spite of their better prognostic effect in the elderly compared with younger counterparts in terms of reducing death and recurrent myocardial infarction [ 19 – 21 ].…”

“…Elderly patients are under-represented in clinical trials resulting in uncertainty of clinicians about impact and benefit of many therapeutic options in this population [ 12 , 13 ] leading to under-prescription of guideline-directed medical therapy (GDMT) in the setting of ACS; among factors that contribute to this under-prescription is the age-related pathophysiological changes resulting in altering pharmacokinetic and pharmacodynamic responses to drugs, the low weight that commonly occurs in elderly, increased bleeding events with use of antithrombotic and antiplatelet therapies, commonly associated anaemia and other comorbidities, and polypharmacy with subsequent drugs interaction [ 14 – 17 ]. However, current study showed more universal use of aspirin and P2Y12 inhibitors in both age groups compared with prior studies [ 12 , 13 , 18 ]. Despite guideline recommendations [ 19 – 21 ] and prognostic benefit, there is a trend to use statin more in the younger group, consistent with earlier studies [ 12 , 18 ].…”

Impact of frailty and atrial fibrillation in elderly patients with acute coronary syndromes

“…Elderly patients are frequently under‐represented in clinical trials, mainly very elderly patients (older than 80 years old) and the information about efficacy and safety of medical therapies and interventional procedures is unknown 14 ; Indeed, elderly patients are less likely to receive evidence‐based therapies 15 . In the LONGEVO‐SCA registry, we observed AF patients received less evidence‐based therapy after an ACS, especially frail AF patients with only 78% of prescription of aspirin and 60.9% of OAC after discharge (both P < .001).…”