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Komatsu J, Nishimura YK, Sugane H, Hosoda H, Imai RI, Nakaoka Y, Nishida K, Mito S, Seki SI, Kubo T, Kitaoka H, Kubokawa SI, Kawai K, Hamashige N, Doi YL. Early Invasive Strategy for Octogenarians and Nonagenarians With Acute Myocardial Infarction. Circ Rep 2024; 6:263-271. [PMID: 38989106 PMCID: PMC11233166 DOI: 10.1253/circrep.cr-24-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 07/12/2024] Open
Abstract
Background: Older adults with acute myocardial infarction (AMI) are currently a rapidly growing population. However, their clinical presentation and outcomes remain unresolved. Methods and Results: A total of 268 consecutive AMI patients were analyzed for clinical characteristics and outcomes with major adverse cardiovascular events (MACE) and all-cause mortality within 1 year. Patients aged ≥80 years (Over-80; n=100) were compared with those aged ≤79 years (Under-79; n=168). (1) Primary percutaneous coronary intervention (PCI) was frequently and similarly performed in both the Over-80 group and the Under-79 group (86% vs. 89%; P=0.52). (2) Killip class III-IV (P<0.01), in-hospital mortality (P<0.01), MACE (P=0.03) and all-cause mortality (P<0.01) were more prevalent in the Over-80 group than in the Under-79 group. (3) In the Over-80 group, frail patients showed a significantly worse clinical outcome compared with non-frail patients. (4) Multivariate analysis revealed Killip class III-IV was associated with MACE (odds ratio [OR]=3.51; P=0.02) and all-cause mortality (OR=9.49; P<0.01) in the Over-80 group. PCI was inversely associated with all-cause mortality (OR=0.13; P=0.02) in the Over-80 group. Conclusions: The rate of primary PCI did not decline with age. Although octogenarians/nonagenarians showed more severe clinical presentation and worse short-term outcomes compared with younger patients, particularly in those with frailty, the prognosis may be improved by early invasive strategy even in these very old patients.
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Affiliation(s)
- Junya Komatsu
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Hiroki Sugane
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Hayato Hosoda
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Yoko Nakaoka
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Koji Nishida
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Shinji Mito
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Shu-Ichi Seki
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Toru Kubo
- Department of Cardiology and Aging Science, Kochi Medical School Kochi Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Aging Science, Kochi Medical School Kochi Japan
| | | | - Kazuya Kawai
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Yoshinori L Doi
- Department of Cardiology, Chikamori Hospital Kochi Japan
- Cardiomyopathy Institute, Chikamori Hospital Kochi Japan
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Liu HH, Li S, Zhang Y, Zhang M, Zhang HW, Qian J, Dou KF, Li JJ. Association of β-blocker use at discharge and prognosis of oldest old with acute myocardial infarction: a prospective cohort study. Eur Geriatr Med 2024; 15:169-178. [PMID: 38103145 DOI: 10.1007/s41999-023-00899-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/11/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE It is uncertain whether β-blockers are beneficial for long-term prognosis in older patients following acute myocardial infarction (AMI). Thus, this study sought to examine the effect of β-blockers on long-term cardiovascular mortality (CVM) in the oldest old (≥ 80 years) with AMI. METHODS In this prospective, consecutive, non-randomized study, a total of 1156 patients with AMI admitted within 24 h after onset of symptoms were enrolled from January 2012 to February 2020. Univariate and multivariate Cox regression analyses were performed to examine the impact of β-blocker use on prognosis. Furthermore, one-to-one propensity score matching (PSM) and inverse probability treatment weighting (IPTW) analyses were used to control for systemic differences between groups. The primary outcome was long-term CVM. RESULTS Among the enrolled subjects, 972 (85.9%) were prescribed with β-blockers at discharge. Over a mean follow-up of 26.3 months, 224 cardiovascular deaths were recorded. Both univariate [hazard ratio (HR), 1.41, 95% confidence interval (CI) 0.93-2.13] and multivariate (HR, 1.29, 95% CI 0.79-2.10) Cox regression analyses showed that β-blocker use had no significant association with the long-term CVM, which was further demonstrated by PSM (HR, 1.31, 95% CI 0.75-2.28) and IPTW (HR, 1.41, 95% CI 0.73-2.69) analyses. Subgroup analyses according to sex, heart rate, hypertension, diabetes, revascularization, left ventricular ejection fraction, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers use showed consistent results as well. CONCLUSION Our findings first suggested that the use of β-blockers at discharge in oldest old with AMI was not useful for reducing post-discharge CVM, which need to be further verified by randomized controlled trials.
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Affiliation(s)
- Hui-Hui Liu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sha Li
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Yan Zhang
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Meng Zhang
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Hui-Wen Zhang
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Jie Qian
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Ke-Fei Dou
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China.
| | - Jian-Jun Li
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China.
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Lapostolle F, Petrovic T, Moiteaux B, Loyeau A, Boche T, Kadji Kalabang R, Le Bail G, Lamhaut L, Lafay M, Dupas F, Scannavino M, Benamer H, Bataille S, Lambert Y. Evolution of REperfusion Strategies and impact on mortality in Old and Very OLD STEMI patients. The RESOVOLD-e-MUST study. Age Ageing 2024; 53:afad215. [PMID: 38167925 PMCID: PMC10762506 DOI: 10.1093/ageing/afad215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The use of myocardial reperfusion-mainly via angioplasty-has increased in our region to over 95%. We wondered whether old and very old patients have benefited from this development. METHODS Setting: Greater Paris Area (Ile-de-France). DATA Regional registry, prospective, including since 2003, data from 39 mobile intensive care units performing prehospital treatment of patients with ST segment elevation myocardial infarction (STEMI) (<24 h). PARAMETERS Demographic, decision to perform reperfusion and outcome (in-hospital mortality). PRIMARY ENDPOINT Reperfusion decision rate by decade over age 70. SECONDARY ENDPOINT Outcome. RESULTS We analysed the prehospital management of 27,294 patients. There were 21,311 (78%) men and 5,919 (22%) women with a median age of 61 (52-73 years). Among these patients, 8,138 (30%) were > 70 years, 3,784 (14%) > 80 years and 672 (2%) > 90 years.The reperfusion decision rate was 94%. It decreased significantly with age: 93, 90 and 76% in patients in their seventh, eighth and ninth decade, respectively. The reperfusion decision rate increased significantly over time. It increased in all age groups, especially the higher ones. Mortality was 6%. It increased significantly with age: 8, 16 and 25% in patients in their seventh, eighth and ninth decade, respectively. It significantly decreased over time in all age groups. The odds ratio of the impact of reperfusion decision on mortality reached 0.42 (0.26-0.68) in patients over 90 years. CONCLUSION the increase in the reperfusion decision rate was the greatest in the oldest patients. It reduced mortality even in patients over 90 years of age.
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Affiliation(s)
- Frédéric Lapostolle
- SAMU 93, UF Recherche-Enseignement-Qualité, Avicenne Hospital-APHP, Bobigny, France
- Université Paris 13, INSERM Unit 942, Sorbonne Paris Cité, Bobigny, France
| | - Tomislav Petrovic
- SAMU 93, UF Recherche-Enseignement-Qualité, Avicenne Hospital-APHP, Bobigny, France
- Université Paris 13, INSERM Unit 942, Sorbonne Paris Cité, Bobigny, France
| | | | | | - Thévy Boche
- SAMU 94, Mondor Hospital-APHP, Créteil, France
| | | | | | | | - Marina Lafay
- SAMU 91, Sud Francilien Hospital, Corbeil-Essonnes, France
| | | | | | - Hakim Benamer
- Cardiology Department, Institut Cardiovasculaire Paris Sud (ICPS), Massy, France
| | | | - Yves Lambert
- SAMU 78, Versailles Hospital, Le Chesnay, France
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De Servi S, Landi A, Savonitto S, Morici N, De Luca L, Montalto C, Crimi G, De Rosa R, De Luca G. Antiplatelet Strategies for Older Patients with Acute Coronary Syndromes: Finding Directions in a Low-Evidence Field. J Clin Med 2023; 12:2082. [PMID: 36902869 PMCID: PMC10003933 DOI: 10.3390/jcm12052082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/23/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023] Open
Abstract
Patients ≥ 75 years of age account for about one third of hospitalizations for acute coronary syndromes (ACS). Since the latest European Society of Cardiology guidelines recommend that older ACS patients use the same diagnostic and interventional strategies used by the younger ones, most elderly patients are currently treated invasively. Therefore, an appropriate dual antiplatelet therapy (DAPT) is indicated as part of the secondary prevention strategy to be implemented in such patients. The choice of the composition and duration of DAPT should be tailored on an individual basis, after careful assessment of the thrombotic and bleeding risk of each patient. Advanced age is a main risk factor for bleeding. Recent data show that in patients of high bleeding risk short DAPT (1 to 3 months) is associated with decreased bleeding complications and similar thrombotic events, as compared to standard 12-month DAPT. Clopidogrel seems the preferable P2Y12 inhibitor, due to a better safety profile than ticagrelor. When the bleeding risk is associated with a high thrombotic risk (a circumstance present in about two thirds of older ACS patients) it is important to tailor the treatment by taking into account the fact that the thrombotic risk is high during the first months after the index event and then wanes gradually over time, whereas the bleeding risk remains constant. Under these circumstances, a de-escalation strategy seems reasonable, starting with DAPT that includes aspirin and low-dose prasugrel (a more potent and reliable P2Y12 inhibitor than clopidogrel) then switching after 2-3 months to DAPT with aspirin and clopidogrel for up to 12 months.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, 27100 Pavia, Italy
| | - Antonio Landi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland
| | | | - Nuccia Morici
- IRCCS S. Maria Nascente—Fondazione Don Carlo Gnocchi ONLUS, 20148 Milan, Italy
| | - Leonardo De Luca
- Department of Cardiovascular Sciences, A.O. San Camillo-Forlanini, 00152 Roma, Italy
| | - Claudio Montalto
- Interventional Cardiology, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
- Clinical and Interventional Cardiology, Istituto Clinico Sant’Ambrogio, Gruppo San Donato, 20122 Milan, Italy
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS, Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Roberta De Rosa
- University Hospital San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
- Goethe University Hospital Frankfurt, 60528 Frankfurt am Main, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU “Policlinico G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, 98039 Messina, Italy
- Division of Cardiology, Nuovo Galeazzi-Sant’Ambrogio Hospital, 20161 Milan, Italy
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Saada M, Kobo O, Polad J, Halabi M, IJsselmuiden AJJ, Puentes Á, Monségu J, Austin D, Baisebenov RK, Spanó F, Roguin A. Prognosis of PCI in AMI setting in the elderly population: Outcomes from the multicenter prospective e-ULTIMASTER registry. Clin Cardiol 2022; 45:1211-1219. [PMID: 36072999 DOI: 10.1002/clc.23902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 07/03/2022] [Accepted: 07/12/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Elderly patients with ST-elevation myocardial infarction (STEMI) who undergo percutaneous coronary intervention (PCI) are usually excluded from major trials. HYOPTHESIS This study sought to assess 1-year clinical outcomes following PCI with a drug-eluting stent in patients older than 80 years old with STEMI. METHODS The large all-comer, multicontinental e-ULTIMASTER registry included 7507 patients with STEMI who underwent PCI using the Ultimaster stent. The primary clinical endpoint was 1-year target lesion failure, a composite of cardiac death (CD), target vessel-related myocardial infarction (TV-MI), or clinically driven target lesion revascularization (CD-TLR). RESULTS There were 457 (6.1%) patients in the elderly group (≥80 years old) that were compared to 7050 (93.9%) patients <80 years. The elderly patients included more female patients and had significantly more comorbidities and had more complex coronary anatomy. The primary endpoint occurred in 7.2% of the elderly, compared to 3.1% of the younger group (p < .001). All-cause mortality was significantly higher among the elderly group compared to the younger group (10.1% vs. 2.3%, p < .0001), as well as CD (6.1% vs. 1.6%, p < .0001), but not TV-MI (1.1% vs. 0.7%, p = .34) or CD-TLR (1.1% vs. 1.4%, p = .63). CONCLUSION Elderly patients with STEMI presentation had a higher incidence of the composite endpoint than younger patients. All-cause and CD were higher for elderly patients compared to patients younger than 80 years old. However, there was no difference in the incidence of TV-MI or target lesion revascularizations. These findings suggest that PCI for STEMI in elderly patients is relatively safe.
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Affiliation(s)
- Majdi Saada
- Department of Cardiology, Hillel Yaffe Medical Center, Technion-Faculty of Medicine, Hadera, Israel
| | - Ofer Kobo
- Department of Cardiology, Hillel Yaffe Medical Center, Technion-Faculty of Medicine, Hadera, Israel
| | - Jawed Polad
- Department of Cardiology, Jeroen Bosch Ziekenhuis, 's Hertogenbosch, The Netherlands
| | - Majdi Halabi
- Department of Cardiology, Ziv Hospital, Safed, Israel
| | | | - Ángel Puentes
- Department of Cardiology, San Juan de Dios Hospital, Santiago, Chile
| | - Jacques Monségu
- Department of Cardiology, Groupe Hospitalier Mutualiste, Institut Cardiovasculaire, Grenoble, France
| | - David Austin
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, UK
| | | | - Fabrizio Spanó
- Department of Cardiology, Meander Medical Center, Amersfoort, The Netherlands
| | - Ariel Roguin
- Department of Cardiology, Hillel Yaffe Medical Center, Technion-Faculty of Medicine, Hadera, Israel
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Okamoto H, Nishi T, Ishii M, Tsujita K, Koto S, Nakai M, Sumita Y, Iwanaga Y, Matoba S, Kobayashi Y, Hirata KI, Hikichi Y, Yokoi H, Ikari Y, Uemura S. Clinical Characteristics and Outcomes of Patients Presenting With Acute Myocardial Infarction Without Cardiogenic Shock. Circ J 2022; 86:1527-1538. [DOI: 10.1253/circj.cj-22-0241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Masanobu Ishii
- Department of Cardiovascular Medicine, Kumamoto University
| | | | - Satoshi Koto
- Department of Cardiology, Kawasaki Medical School
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center
| | - Yoko Sumita
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Ken-ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yutaka Hikichi
- Department of Cardiology, Saga-Ken Medical Centre Koseikan
| | | | - Yuji Ikari
- Department of Cardiovascular Medicine, Tokai University School of Medicine
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
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7
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Putot A, Putot S, Chagué F, Cottin Y, Zeller M, Manckoundia P. New horizons in Type 2 myocardial infarction: pathogenesis, assessment and management of an emerging geriatric disease. Age Ageing 2022; 51:6565797. [PMID: 35397160 DOI: 10.1093/ageing/afac085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Indexed: 11/13/2022] Open
Abstract
Type 2 myocardial infarction (MI) is characterised by a functional imbalance between myocardial oxygen supply and demand in the absence of a thrombotic process, leading to myocardial necrosis. This type of MI was relatively unknown among clinicians until the third universal definition of MI was published in 2017, differentiating Type 2 from Type 1 MI, which follows an acute atherothrombotic event. The pathogenesis, diagnostic and therapeutic aspects of Type 2 MI are described in the present review. Type 2 MI is a condition that is strongly linked to age because of vascular ageing concerning both epicardic vessels and microcirculation, age-related atherosclerosis and stress maladaptation. This condition predominantly affects multimorbid individuals with a history of cardiovascular disease. However, the conditions that lead to the functional imbalance between oxygen supply and demand are frequently extra-cardiac (e.g. pneumonia or anaemia). The great heterogeneity of the underlying etiological factors requires a comprehensive approach that is tailored to each case. In the absence of evidence for the benefit of invasive reperfusion strategies, the treatment of Type 2 MI remains to date essentially based on the restoration of the balance between oxygen supply and demand. For older co-morbid patients with Type 2 MI, geriatricians and cardiologists need to work together to optimise etiological investigations, treatment and prevention of predisposing conditions and precipitating factors.
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Affiliation(s)
- Alain Putot
- Unité Post Urgence Gériatrique, Centre Hospitalier Universitaire Sud Réunion, 97410 Saint Pierre, France
- Laboratoire Physiopathologie et Epidémiologie Cérébro-Cardiovasculaire – EA7460, Université de Bourgogne Franche Comté, 21000 Dijon, France
| | - Sophie Putot
- Unité Post Urgence Gériatrique, Centre Hospitalier Universitaire Sud Réunion, 97410 Saint Pierre, France
| | - Frédéric Chagué
- Service de Cardiologie, Centre Hospitalier Universitaire Dijon Bourgogne, 21000 Dijon, France
| | - Yves Cottin
- Service de Cardiologie, Centre Hospitalier Universitaire Dijon Bourgogne, 21000 Dijon, France
| | - Marianne Zeller
- Laboratoire Physiopathologie et Epidémiologie Cérébro-Cardiovasculaire – EA7460, Université de Bourgogne Franche Comté, 21000 Dijon, France
| | - Patrick Manckoundia
- Service de Médecine Interne Gériatrie, Centre Hospitalier Universitaire Dijon Bourgogne, 21000 Dijon, France
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García-Blas S, Cordero A, Diez-Villanueva P, Martinez-Avial M, Ayesta A, Ariza-Solé A, Mateus-Porta G, Martínez-Sellés M, Escribano D, Gabaldon-Perez A, Bodi V, Bonanad C. Acute Coronary Syndrome in the Older Patient. J Clin Med 2021; 10:4132. [PMID: 34575243 PMCID: PMC8467899 DOI: 10.3390/jcm10184132] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 01/21/2023] Open
Abstract
Coronary artery disease is one of the leading causes of morbidity and mortality, and its prevalence increases with age. The growing number of older patients and their differential characteristics make its management a challenge in clinical practice. The aim of this review is to summarize the state-of-the-art in diagnosis and treatment of acute coronary syndromes in this subgroup of patients. This comprises peculiarities of ST-segment elevation myocardial infarction (STEMI) management, updated evidence of non-STEMI therapeutic strategies, individualization of antiplatelet treatment (weighting ischemic and hemorrhagic risks), as well as assessment of geriatric conditions and ethical issues in decision making.
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Affiliation(s)
- Sergio García-Blas
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
| | - Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain
| | - Pablo Diez-Villanueva
- Cardiology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (P.D.-V.); (M.M.-A.)
| | - Maria Martinez-Avial
- Cardiology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (P.D.-V.); (M.M.-A.)
| | - Ana Ayesta
- Cardiology Department, Hospital Central de Asturias, 33011 Oviedo, Spain;
| | - Albert Ariza-Solé
- Cardiology Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.A.-S.); (G.M.-P.)
| | - Gemma Mateus-Porta
- Cardiology Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.A.-S.); (G.M.-P.)
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, 28007 Madrid, Spain
| | - David Escribano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain
| | - Ana Gabaldon-Perez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
| | - Vicente Bodi
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
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9
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Morici N, De Servi S, De Luca L, Crimi G, Montalto C, De Rosa R, De Luca G, Rubboli A, Valgimigli M, Savonitto S. Management of acute coronary syndromes in older adults. Eur Heart J 2021; 43:1542-1553. [PMID: 34347065 DOI: 10.1093/eurheartj/ehab391] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/03/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Older patients are underrepresented in prospective studies and randomized clinical trials of acute coronary syndromes (ACS). Over the last decade, a few specific trials have been conducted in this population, allowing more evidence-based management. Older adults are a heterogeneous, complex, and high-risk group whose management requires a multidimensional clinical approach beyond coronary anatomic variables. This review focuses on available data informing evidence-based interventional and pharmacological approaches for older adults with ACS, including guideline-directed management. Overall, an invasive approach appears to demonstrate a better benefit-risk ratio compared to a conservative one across the ACS spectrum, even considering patients' clinical complexity and multiple comorbidities. Conversely, more powerful strategies of antithrombotic therapy for secondary prevention have been associated with increased bleeding events and no benefit in terms of mortality reduction. An interdisciplinary evaluation with geriatric assessment should always be considered to achieve a holistic approach and optimize any treatment on the basis of the underlying biological vulnerability.
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Affiliation(s)
- Nuccia Morici
- Unità di Cure Intensive Cardiologiche, and De Gasperis Cardio-Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | | | - Leonardo De Luca
- Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - Gabriele Crimi
- Cardio Thoraco Vascular Department (DICATOV), Interventional Cardiology Unit, IRCCS Policlinico San Martino, Genova, Italy
| | | | - Roberta De Rosa
- Department of Cardiology, Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU Maggiore della Carità, Università del Piemonte Orientale, Novara, Italy
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Disease-AUSL Romagna, Ospedale S. Maria delle Croci, Ravenna, Italy
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Audigane L, Persello A, Piriou N, Ferron M, Trochu JN, Lauzier B, Gauthier C, Rozec B. Early nebivolol treatment is beneficial in myocardial infarction in rats partly through β3-adrenoceptor remodelling. Clin Exp Pharmacol Physiol 2021; 48:1007-1015. [PMID: 33314348 DOI: 10.1111/1440-1681.13447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/29/2020] [Indexed: 11/28/2022]
Abstract
It remains unknown whether β-blockers are useful and safe in acute myocardial infarction (MI). Owing to its pharmacological profile and vasodilating action, nebivolol (N) is useful in MI. The aim of the present study was to assess in rat whether early nebivolol treatment could be beneficial in MI. It remains unknown whether β-blockers are useful and safe in acute MI. On day (D) 0, male Sprague-Dawley rats underwent left coronary artery ligation (MI) or simple thoracotomy (SHAM). On D1 and D2, the rats were treated with either nebivolol (5 mg.kg-1 .day-1 , MI-N and Sham-N) or vehicle (V, MI-V and Sham-V). On D3, heart rate, left ventricle (LV) intrinsic contractility (PESmid) and arterial elastance were measured. Cardiac and aortic β-Adrenoceptor (AR) subtype mRNA were quantified using real time quantitative RT-qPCR. Catecholamine response was assessed on isolated heart and aortic rings with isoproterenol. PESmid was decreased in MI without worsening the decrease nebivolol. In LV, β1 - and β3 -AR mRNA were respectively decreased and increased in all MI. β3 -AR mRNA increase was partly limited by nebivolol. Ex vivo, basal contractility was less decreased in MI-N than in MI-V. Isoproterenol response was only altered in MI-V. In MI aorta, Nebi prevented β2 - and β3 -AR mRNA increases. In addition, Acetylcholine-induced relaxation was lowered in MI-V but preserved with nebivolol. We demonstrated an early modulation of cardiovascular β3 -AR transcription early MI. Despite its putative negative inotropic properties, nebivolol did not worsen cardiac function in basal conditions and preserved LV catecholamine response.
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Affiliation(s)
- Leslie Audigane
- L'institut du thorax, INSERM, CNRS, CHU Nantes Nantes, UNIV Nantes, Nantes, France
| | - Antoine Persello
- L'institut du thorax, INSERM, CNRS, CHU Nantes Nantes, UNIV Nantes, Nantes, France
- InFlectis BioScience, Nantes, France
| | - Nicolas Piriou
- L'institut du thorax, INSERM, CNRS, CHU Nantes Nantes, UNIV Nantes, Nantes, France
| | - Marine Ferron
- L'institut du thorax, INSERM, CNRS, CHU Nantes Nantes, UNIV Nantes, Nantes, France
| | - Jean-Noël Trochu
- L'institut du thorax, INSERM, CNRS, CHU Nantes Nantes, UNIV Nantes, Nantes, France
| | - Benjamin Lauzier
- L'institut du thorax, INSERM, CNRS, CHU Nantes Nantes, UNIV Nantes, Nantes, France
| | - Chantal Gauthier
- L'institut du thorax, INSERM, CNRS, CHU Nantes Nantes, UNIV Nantes, Nantes, France
| | - Bertrand Rozec
- L'institut du thorax, INSERM, CNRS, CHU Nantes Nantes, UNIV Nantes, Nantes, France
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11
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Dillinger JG, Laine M, Bouajila S, Paganelli F, Henry P, Bonello L. Antithrombotic strategies in elderly patients with acute coronary syndrome. Arch Cardiovasc Dis 2021; 114:232-245. [PMID: 33632631 DOI: 10.1016/j.acvd.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 12/22/2022]
Abstract
Elderly patients represent a growing proportion of the acute coronary syndrome population in Western countries. However, their frequent atypical symptoms at presentation often lead to delays in management and to misdiagnosis. Furthermore, their prognosis is poorer than that of younger patients because of physiological changes in platelet function, haemostasis and fibrinolysis, but also a higher proportion of comorbidities and frailty, both of which increase the risk of recurrent thrombotic and bleeding events. This complex situation, with ischaemic and haemorrhagic risk factors often being intertwined, may lead to confusion about the required treatment strategy, sometimes resulting in inadequate management or even to therapeutic nihilism. It is therefore critical to provide a comprehensive overview of our understanding of the pathophysiological processes underlying acute coronary syndrome in elderly patients, and to summarise the results from the latest clinical trials to help decision making for these high-risk patients.
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Affiliation(s)
- Jean-Guillaume Dillinger
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France.
| | - Marc Laine
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France; Mediterranean Association for research and studies in cardiology (MARS cardio), 13015 Marseille, France
| | - Sara Bouajila
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Franck Paganelli
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France
| | - Patrick Henry
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Laurent Bonello
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France; Mediterranean Association for research and studies in cardiology (MARS cardio), 13015 Marseille, France
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12
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Managing Nonagenarians with Acute Myocardial Infarction: Invasive versus Conservative Treatment. Cardiol Res Pract 2020; 2020:8885518. [PMID: 33224527 PMCID: PMC7671813 DOI: 10.1155/2020/8885518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/08/2020] [Accepted: 10/30/2020] [Indexed: 12/27/2022] Open
Abstract
Background Limited data are available to support an invasive treatment strategy in nonagenarians with acute myocardial infarction (AMI). We aimed to investigate whether percutaneous coronary intervention (PCI) is beneficial in this frail population. Methods We retrospectively analyzed 41 nonagenarians with AMI (both ST-segment-elevation and non-ST-segment-elevation MI) between 2006 and 2015 in a single center. We assessed 30-day and one-year mortality rates according to the treatment strategy. Results Among study subjects, 24 (59%) were treated with PCI (PCI group) and 17 (41%) were treated with conservative management (medical treatment group) per the clinician's discretion. The median follow-up duration was 30 months (0–74 months). Thirty-day mortality was lower in the PCI group than in the medical treatment group (17% vs. 65%; P < 0.001). One-year mortality was also lower in the PCI group than in the medical treatment group (21% vs. 76%; P < 0.001). The PCI group presented a 73% decreased risk of death (adjusted hazard ratio: 0.269; 95% confidence interval: 0.126–0.571; P < 0.001). In the Killip class 1 through 3 subgroups (n = 36), 30-day and one-year mortality were still higher among those in the medical treatment group (13% vs. 54% at 30 days; P < 0.001 and 17% vs. 69% at one year; P < 0.001). Landmark analysis after 30 days revealed no significant difference in the cumulative mortality rate between the two groups, indicating that the mortality difference was mainly determined within the first 30 days after AMI. Conclusion Mortality after AMI was decreased in correlation with the invasive strategy relative to the conservative strategy, even in nonagenarians. Regardless of age, PCI should be considered in AMI patients. However, large-scale randomized controlled trials are needed to support our conclusion.
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13
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Kikuchi N, Ogawa H, Kawada‐Watanabe E, Arashi H, Jujo K, Sekiguchi H, Yamaguchi J, Hagiwara N. Impact of age on clinical outcomes of antihypertensive therapy in patients with hypertension and coronary artery disease: A sub‐analysis of the Heart Institute of Japan Candesartan Randomized Trial for Evaluation in Coronary Artery Disease. J Clin Hypertens (Greenwich) 2020; 22:1070-1079. [DOI: 10.1111/jch.13891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 03/29/2020] [Accepted: 04/05/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Noriko Kikuchi
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Hiroshi Ogawa
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Erisa Kawada‐Watanabe
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Hiroyuki Arashi
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Kentaro Jujo
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Haruki Sekiguchi
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Junichi Yamaguchi
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
| | - Nobuhisa Hagiwara
- Department of CardiologyThe Heart Institute of JapanTokyo Women's Medical University Tokyo Japan
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14
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Mouhat B, Putot A, Hanon O, Eicher JC, Chagué F, Beer JC, Maza M, Zeller M, Cottin Y. Low Systolic Blood Pressure and Mortality in Elderly Patients After Acute Myocardial Infarction. J Am Heart Assoc 2020; 9:e013030. [PMID: 32098597 PMCID: PMC7335552 DOI: 10.1161/jaha.119.013030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Optimal blood pressure in elderly patients after acute myocardial infarction is still a matter of debate. In a prospective observational study, we aimed to identify optimal systolic blood pressure during the 48 first hours after admission for acute myocardial infarction and its prognostic value for cardiovascular mortality. Methods and Results From the Observatoire des Infarctus de Côte d'Or survey, all consecutive patients aged >75 years admitted for an acute myocardial infarction in a coronary care unit from 2012 to 2015 and discharged alive were included (n=814). Exclusion criteria were in‐hospital death, cardiogenic shock, and end‐stage renal disease. Average systolic blood pressure (aSBP) values over the first 48 hours after admission were recorded, and the population was dichotomized into 2 groups: low aSBP group (<125 mm Hg) and control group (aSBP ≥125 mm Hg). When compared with patients without cardiovascular death at 1‐year follow‐up, patients who died from a cardiovascular cause had higher rate of cardiovascular risks factors, including age, diabetes mellitus, comorbidities, and cardiovascular history. They had higher rates of low body mass index (<21 kg/m2) and more elevated Global Registry of Acute Coronary Events risk score. Patients with aSBP <125 mm Hg had a 2‐fold risk of 1‐year cardiovascular death (47 [12.0%] versus 28 [6.6%]; P=0.008). By multivariable logistic regression analysis, low aSBP (odds ratio [95% CI], 1.91 [1.07–3.41]) remained a strong and independent predictor of 1‐year cardiovascular mortality. Conclusions In our large population‐based study in elderly patients with acute myocardial infarction, low aSBP was an independent and powerful predictor of 1‐year cardiovascular mortality. Early aSBP measurement could help to improve risk stratification. Moreover, our results may suggest an optimal blood pressure target in elderly patients.
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Affiliation(s)
- Basile Mouhat
- Service de Cardiologie CHU Dijon Dijon France.,Laboratoire Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires EA 7460 Université de Bourgogne Franche-Comté Dijon France
| | - Alain Putot
- Médecine Interne Gériatrie Pôle Personnes Âgées Centre Hospitalier Universitaire de Dijon Dijon France
| | - Olivier Hanon
- Service de Gériatrie Assistance Publique - Hôpitaux de Paris Hôpital Broca Paris France.,EA 4468 Université Paris Descartes Sorbonne Paris Cité, Paris France
| | | | | | | | - Maud Maza
- Service de Cardiologie CHU Dijon Dijon France
| | - Marianne Zeller
- Laboratoire Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires EA 7460 Université de Bourgogne Franche-Comté Dijon France
| | - Yves Cottin
- Service de Cardiologie CHU Dijon Dijon France
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15
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Verdoia M, Nardin M, Negro F, Tonon F, Gioscia R, Rolla R, De Luca G. Impact of aging on immature platelet count and its relationship with coronary artery disease. Platelets 2020; 31:1060-1068. [PMID: 31973643 DOI: 10.1080/09537104.2020.1714572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Despite the fact that elderly patients represent a prevalent and challenging population in the current practice, few data exist on the impact of platelet parameters on cardiovascular risk in these patients. Therefore, the aim of the present study was to evaluate the impact of age on the immature platelet count (IPC) and their relationship with CAD. We included a total of 2236 consecutive patients undergoing coronary angiography in a single center. Elderly patients (age ≥ 75 years) were 756 (33.7%). IPC was measured at admission. Elderly patients were more often females (p < .001), with lower BMI and prevalence of smokers (p < .001), and a more complex cardiovascular risk profile and coronary disease (p = .02). Platelet count decreased with aging (p = .05), whereas no difference in the mean IPC was found between patients < or ≥75 years. In fact, advanced age did not emerge as an independent predictor of IPC above III tertile (≥8.6*10^6/ml), (adjusted OR[95%CI] = 0.97[0.78-1.21], p = .79). When considering elderly patients according to tertiles values of IPC (<5.1,5.1-8.59; ≥8.6*10^6/ml), we found no impact of IPC on the prevalence of CAD (81.1% vs 84.5% vs 81.5%, p = .92; adjusted OR[95%CI] = 1.08[0.67-1.72], p = .75) and its extent (37.7% vs 34.5% vs 40.2%, p = .57; adjusted OR[95%CI] = 1.22[0.85-1.73], p = .28). However, we observed a higher rate of calcified and type C lesions in elderly patients with higher IPC (p = .03 and p < .001, respectively). Therefore, advanced age is not associated with higher immature platelet count and the prevalence and severity of CAD. Moreover, IPC does not contribute to explain the higher prevalence and extent of coronary artery disease observed in elderly patients.
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Affiliation(s)
- Monica Verdoia
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Matteo Nardin
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy.,Department of Medicine, ASST "Spedali Civili", University of Brescia , Brescia, Italy
| | - Federica Negro
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Francesco Tonon
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Rocco Gioscia
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Roberta Rolla
- Department of Clinical Chemistry, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
| | - Giuseppe De Luca
- Department of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University , Novara, Italy
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16
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Crimi G, Morici N, Ferrario M, Ferri LA, Piatti L, Grosseto D, Cacucci M, Mandurino Mirizzi A, Toso A, Piscione F, De Carlo M, Elia LR, Trimarco B, Bolognese L, Bovenzi FM, De Luca G, Savonitto S, De Servi S. Time Course of Ischemic and Bleeding Burden in Elderly Patients With Acute Coronary Syndromes Randomized to Low-Dose Prasugrel or Clopidogrel. J Am Heart Assoc 2020; 8:e010956. [PMID: 30636561 PMCID: PMC6497351 DOI: 10.1161/jaha.118.010956] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Elderly patients have high ischemic and bleeding rates after acute coronary syndrome; however, the occurrence of these complications over time has never been studied. This study sought to characterize average daily ischemic rates ( ADIRs ) and average daily bleeding rates ( ADBRs ) over 1 year in patients aged >74 years with acute coronary syndrome undergoing percutaneous coronary intervention who were randomized in the Elderly ACS 2 trial, comparing low-dose prasugrel (5 mg daily) with clopidogrel (75 mg daily). Methods and Results ADIRs and ADBRs were calculated as the total number of events, including recurrent events, divided by the number of patient-days of follow-up and assessed within different clinical phases: acute (0-3 days), subacute (4-30 days), and late (31-365 days). Generalized estimating equations were used to test the least squares mean differences for the pairwise comparisons of ADIRs and ADBRs and the pairwise comparison of clopidogrel versus prasugrel effects. Globally, ADIRs were 2.6 times (95% CI, 2.4-2.9) higher than ADBRs . ADIRs were significantly higher in the clopidogrel arm than in the low-dose prasugrel arm in the subacute phase ( Padj<0.001) without a difference in ADBRs ( Padj=0.35). In the late phase, ADIRs remained significantly higher with clopidogrel ( Padj<0.001), whereas ADBRs were significantly higher with low-dose prasugrel ( Padj<0.001). Conclusions Ischemic burden was greater than bleeding burden in all clinical phases of 1-year follow-up of elderly patients with acute coronary syndrome treated with percutaneous coronary intervention. Low-dose prasugrel reduced ischemic events in the subacute and chronic phases compared with clopidogrel, whereas bleeding burden was lower with clopidogrel in the late phase. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01777503.
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Affiliation(s)
- Gabriele Crimi
- 1 Division of Cardiology IRCCS Fondazione Policlinico S. Matteo Pavia Italy
| | - Nuccia Morici
- 2 First Division of Cardiology Ospedale Niguarda Milano Italy
| | - Maurizio Ferrario
- 1 Division of Cardiology IRCCS Fondazione Policlinico S. Matteo Pavia Italy
| | - Luca A Ferri
- 3 Division of Cardiology Ospedale Manzoni Lecco Italy
| | - Luigi Piatti
- 3 Division of Cardiology Ospedale Manzoni Lecco Italy
| | | | | | | | - Anna Toso
- 6 Division of Cardiology Ospedale S. Stefano Prato Italy
| | - Federico Piscione
- 7 Department of Medicine, Surgery and Dentistry-Schola Medica Salernitana University of Salerno Italy
| | - Marco De Carlo
- 8 Cardiac Catheterization Laboratory Cardiothoracic and Vascular Department Azienda Ospedaliero-Universitaria Pisana Pisa Italy
| | - Luigi Raffaele Elia
- 9 Division of Cardiology and Intensive Care Unit Ospedale Cardarelli Napoli Italy
| | - Bruno Trimarco
- 10 Division of Cardiology Policlinico Universitario Federico II Napoli Italy
| | | | | | - Giuseppe De Luca
- 13 Division of Cardiology Azienda Ospedaliera-Universitaria "Maggiore della Carità" Eastern Piedmont University Novara Italy
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Briet C, Blanchart K, Lemaître A, Roux I, Lavergne K, Rocamora A, Bignon M, Ardouin P, Sabatier R, Roule V, Beygui F. Bedside mental status and outcome in elderly patients admitted for acute coronary syndromes. Heart 2019; 105:1635-1641. [DOI: 10.1136/heartjnl-2019-314978] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/27/2019] [Accepted: 05/09/2019] [Indexed: 11/04/2022] Open
Abstract
ObjectiveWe investigated whether mental status assessed by simple bedside tests in elderly patients admitted for acute coronary syndromes (ACS) was associated with higher risk of mortality.MethodsWe used the data from a prospective, open, ongoing cohort of patients≥75 years old admitted for ACS to a tertiary centre. Cognitive impairment (CogI) was defined by delirium detected by the Confusion Assessment Method or an abnormal Mini Mental State Examination score. A Cox model adjusted on predefined correlates of mortality was used to assess the relationship between CogI and 1-year mortality.ResultsSix-hundred consecutive patients with mental status assessment within 48 hours after admission were included. CogI was identified in 172 (29%) patients among whom 153 (25.5%) had an abnormal Mini Mental State Evaluation and 19 (3.2%) delirium. Death occurred in 49 (28.6%) patients with and 43 (10.5%) patients without CogI at 1 year. There was a significant association between CogI and 1-year mortality (adjusted-HR 2.4, 95% CI 1.53 to 3.62), p<0.001) independent of other covariables. CogI was also independently associated with higher rates of in-hospital bleeding and mortality as well as 3-month rates of all-cause, cardiovascular-related and heart failure-related rehospitalisation.ConclusionsCogI detected by simple bedside tests in patients≥75 admitted for ACS is associated with an increased risk of 1-year mortality and 3 month rehospitalisation independent of other correlates of poor outcome.
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Comparative performance of AnTicoagulation and Risk factors In Atrial fibrillation and Global Registry of Acute Coronary Events risk scores in predicting long-term adverse events in patients with acute myocardial infarction. Anatol J Cardiol 2019; 20:77-84. [PMID: 30088481 PMCID: PMC6237955 DOI: 10.14744/anatoljcardiol.2018.54815] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective: This study is designed to evaluate the recently developed AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) risk score (RS), which determines the predisposition to thromboembolic and hemorrhagic events in atrial fibrillation, as a predictor of prognosis in patients having acute myocardial infarction (AMI), and to compare the predictive ability of ATRIA RS with GRACE RS. Methods: We analyzed 1627 patients having AMI who underwent coronary angiography and/or percutaneous coronary intervention (PCI) between January 2011 and February 2015. The primary endpoints included all-cause mortality, non-fatal MI, and cerebrovascular events during follow-up. Results: Multivariate Cox regression analysis showed that the ATRIA RS>3 was an independent predictor of major adverse cardiac events in patients with AMI [hazard ratio, 2.00, 95% confidence interval, 1.54 to 2.60, p<0,001]. The area under the curve (AUC) for ATRIA RS and GRACE RS was 0.66 and 0.67 (p<0.001, and p<0.001), respectively. We performed a pair-wise comparison of receiver operating characteristic curves, and noted the predictive value of ATRIA RS with regard to primary endpoints was similar to that of GRACE RS (By DeLong method, AUCATRIA vs. AUCGRACE z test=0.64, p=0.52). Conclusion: ATRIA RS may be useful in predicting prognosis in patients having AMI during long-term follow-up.
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It’s not ageing, stupid: why population ageing won’t bankrupt health systems. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:195-201. [DOI: 10.1093/ehjqcco/qcz022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/15/2019] [Accepted: 04/25/2019] [Indexed: 11/14/2022]
Abstract
Abstract
An ageing population is often viewed as a factor that will increase healthcare expenditures (HCE) to unsustainable levels. With nearly half the disease burden in high-income countries arising in older people, there are concerns that caring for a burgeoning older population that is sick and dependent on support will not be possible. The aim of this narrative review is to examine how population ageing is likely to affect future HCE growth. We find that despite the increasing share of older people over the next few decades, the changing age-mix will not be a significant driver of HCE growth. While older people, on average, incur higher per person healthcare spending than younger people, the proportions of the population at the oldest and most costly age groups increase very slowly over time. In the European Union, we estimate the changing age-mix to result in the increase of the average annual growth in per person health spending by no more than 0.6 additional percentage points per year between 2015 and 2050. Therefore, price growth and technological advancements, independent of population ageing, will be the main contributors to future HCE growth.
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Comparison of One-Year Survival After Acute Coronary Syndrome in Patients ≥75 Years of Age With Versus Without Living With Spouse. Am J Cardiol 2019; 123:1-6. [PMID: 30539743 DOI: 10.1016/j.amjcard.2018.09.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/06/2018] [Accepted: 09/13/2018] [Indexed: 02/08/2023]
Abstract
Patients with acute coronary syndrome (ACS) face high postevent mortality. This study aims to evaluate the impact of living without spouse on 1-year mortality of ACS patients. This retrospective study enrolled a total of 600 consecutive patients (≥75 years of age) with ACS hospitalized in our hospital between January 2013 and December 2016. Patients' clinical characteristics, laboratory values, hospital course, demographic characteristics, and angiographic data were collected. Patients were divided into 2 groups according to living with (n = 396) or without (n = 204) spouse. Patients living without spouse were older (79 [77,82] vs 77 [76,80], p <0.001), more frequently female (54.9% vs 31.8%, p <0.001), less smokers (23.5% vs 38.9%, p <0.001), lower left ventricular ejection fraction value (52.1±10.7% vs 54.4±9.8%, p = 0.021) compared with patients living with spouse. In addition, compared to patients living with spouse, patients living without spouse were less likely to get percutaneous coronary intervention (41.2% vs 54.0%, p = 0.003) during hospitalization and had higher 1-year mortality post-ACS (22.1% vs 13.4%, p = 0.006). Multivariate logistic regression analysis showed that living without spouse remained an independent risk factor for 1-year mortality after ACS in patients ≥75 years (odds ratio 2.350, 95% confidence interval 1.245 to 4.434, p = 0.008), after adjusted with age, gender, heart rate, systolic blood pressure, left ventricular ejection fraction value at baseline, hemoglobin, white blood cell, alanine aminotransferase, albumin, creatinine, brain natriuretic peptide, type of ACS, severe heart failure at admission, percutaneous coronary intervention treatment, β blocker, diuretics application during hospital. In conclusion, living without spouse is an independent risk factor for 1-year all-cause mortality in ACS patients ≥75 years.
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21
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Varghese T, Wenger NK. Non-ST elevation acute coronary syndrome in women and the elderly: recent updates and stones still left unturned. F1000Res 2018; 7:F1000 Faculty Rev-1865. [PMID: 30631426 PMCID: PMC6281006 DOI: 10.12688/f1000research.16492.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2018] [Indexed: 12/17/2022] Open
Abstract
Despite the growing awareness of adverse events with acute coronary syndrome and vigilance to refine pharmacological and interventional therapies, the understanding of how these events present in and affect women and the elderly remains limited. Pathophysiological differences in these subgroups and under-representation in large trials create a medical gap in sex- and age-related outcomes and in our knowledge of how best to detect, diagnose, and treat acute coronary syndrome. This review provides a general overview of recent advances in non-ST elevation myocardial infarction management in women and the elderly and elucidates areas where further exploration is needed.
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Affiliation(s)
- Tina Varghese
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nanette K. Wenger
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
- Emory Heart and Vascular Center, Emory Women's Heart Center, Atlanta, GA, USA
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22
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Savonitto S, Ferri LA, Piatti L, Grosseto D, Piovaccari G, Morici N, Bossi I, Sganzerla P, Tortorella G, Cacucci M, Ferrario M, Murena E, Sibilio G, Tondi S, Toso A, Bongioanni S, Ravera A, Corrada E, Mariani M, Di Ascenzo L, Petronio AS, Cavallini C, Vitrella G, Rogacka R, Antonicelli R, Cesana BM, De Luca L, Ottani F, De Luca G, Piscione F, Moffa N, De Servi S, Bolognese L, Bovenzi F, Steffenino G, Santilli I, Bassanelli G, Sacco A, Canziani F, Ferri M, Lo Jacono E, Canosi U, Fornaro G, Leoncini M, Rosa Conte M, Farina R, Stefanin C, Di Pede F, Chella P, Chiara Nardoni M, Tamburrini P, Trimarco B, Galasso G, Elia R, Bolognese L, Grotti S, Bovenzi F, Borrelli L, Tamburino C, Capranzano P, Francaviglia B, Campana C, Bonatti R, Martinoni A, Abate F, Coscarelli S, Rubartelli P, Villani GQ, Rossini R. Comparison of Reduced-Dose Prasugrel and Standard-Dose Clopidogrel in Elderly Patients With Acute Coronary Syndromes Undergoing Early Percutaneous Revascularization. Circulation 2018; 137:2435-2445. [DOI: 10.1161/circulationaha.117.032180] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/02/2018] [Indexed: 11/16/2022]
Abstract
Background:
Elderly patients are at elevated risk of both ischemic and bleeding complications after an acute coronary syndrome and display higher on-clopidogrel platelet reactivity compared with younger patients. Prasugrel 5 mg provides more predictable platelet inhibition compared with clopidogrel in the elderly, suggesting the possibility of reducing ischemic events without increasing bleeding.
Methods:
In a multicenter, randomized, open-label, blinded end point trial, we compared a once-daily maintenance dose of prasugrel 5 mg with the standard clopidogrel 75 mg in patients >74 years of age with acute coronary syndrome undergoing percutaneous coronary intervention. The primary end point was the composite of mortality, myocardial infarction, disabling stroke, and rehospitalization for cardiovascular causes or bleeding within 1 year. The study was designed to demonstrate superiority of prasugrel 5 mg over clopidogrel 75 mg.
Results:
Enrollment was interrupted, according to prespecified criteria, after a planned interim analysis, when 1443 patients (40% women; mean age, 80 years) had been enrolled with a median follow-up of 12 months, because of futility for efficacy. The primary end point occurred in 121 patients (17%) with prasugrel and 121 (16.6%) with clopidogrel (hazard ratio, 1.007; 95% confidence interval, 0.78–1.30;
P
=0.955). Definite/probable stent thrombosis rates were 0.7% with prasugrel versus 1.9% with clopidogrel (odds ratio, 0.36; 95% confidence interval, 0.13–1.00;
P
=0.06). Bleeding Academic Research Consortium types 2 and greater rates were 4.1% with prasugrel versus 2.7% with clopidogrel (odds ratio, 1.52; 95% confidence interval, 0.85–3.16;
P
=0.18).
Conclusions:
The present study in elderly patients with acute coronary syndromes showed no difference in the primary end point between reduced-dose prasugrel and standard-dose clopidogrel. However, the study should be interpreted in light of the premature termination of the trial.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01777503.
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Affiliation(s)
| | | | - Luigi Piatti
- Ospedale Manzoni, Lecco, Italy (S.S., L.A.F., L.P.)
| | | | | | - Nuccia Morici
- Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy (N. Morici, I.B.)
| | - Irene Bossi
- Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy (N. Morici, I.B.)
| | | | - Giovanni Tortorella
- Istituto di Ricerca e Cura a Carattere Scientifico Arcispedale S. Maria Nuova, Reggio Emilia, Italy (G.T.)
| | | | | | - Ernesto Murena
- Ospedale S. Maria delle Grazie, Pozzuoli, Italy (E.M., G.S.)
| | | | | | - Anna Toso
- Ospedale S. Stefano, Prato, Italy (A.T.)
| | | | | | - Elena Corrada
- Humanitas Clinical and Research Center, Rozzano, Italy (E.C.)
| | | | | | | | | | | | - Renata Rogacka
- Azienda Ospedaliera di Desio e Vimercate, Desio, Italy (R.R.)
| | | | - Bruno M. Cesana
- Statistics and Biomathematics Unit, Department of Molecular and Transactional Medicine, University of Brescia, Italy (B.M.C.)
| | | | | | - Giuseppe De Luca
- Azienda Ospedaliera-Universitaria “Maggiore della Carità,” Eastern Piedmont University, Novara, Italy (G.D.L.)
| | - Federico Piscione
- Department of Medicine, Surgery and Dentistry–Schola Medica Salernitana, University of Salerno, Italy (F.P.)
| | - Nadia Moffa
- Mediolanum Cardio Research, Milan, Italy (N. Moffa)
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23
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Zabawa C, Cottenet J, Zeller M, Mercier G, Rodwin VG, Cottin Y, Quantin C. Thirty-day rehospitalizations among elderly patients with acute myocardial infarction: Impact of postdischarge ambulatory care. Medicine (Baltimore) 2018; 97:e11085. [PMID: 29901621 PMCID: PMC6023939 DOI: 10.1097/md.0000000000011085] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Rehospitalization after acute myocardial infarction (AMI) is common in elderly patients. It increases morbimortality and health care expenditures. The association between ambulatory care after discharge for AMI and rehospitalization has never been studied in France. We analyzed the impact of ambulatory care on rehospitalization of elderly patients (≥65 years) within 30 days after hospital discharge.We conducted a nationwide population-based study of elderly patients hospitalized with a main diagnosis of AMI in France between 2011 and 2013. We excluded patients hospitalized for AMI in the previous year and those who died during the index hospitalization or within 30 days after discharge. The primary outcome was the first all-cause 30-day rehospitalization in an acute care hospital. Individual and neighborhood-level variables were compared among rehospitalized and nonrehospitalized patients. Determinants of 30-day rehospitalization were identified using logistic regression models.Among the 624 eligible patients, 137 (22.0%) were rehospitalized within 30 days after discharge. In multivariate analyses, chronic kidney failure (odds ratio [OR] 1.88; 95% confidence interval [CI], 1.01-3.53) was an independent predictor of 30-day rehospitalization. We found no association among deprivation and spatial accessibility measures and 30-day rehospitalization. The purchase of lipid-lowering drugs prescription within 7 days after discharge was associated with a reduced risk of 30-day rehospitalization (OR 0.53; 95% CI, 0.36-0.79).This study highlights the role of coordination among hospital and primary care physicians in post-AMI discharge and follow-up among elderly patients. Specifically, targeted interventions to reduce 30-day rehospitalizations should focus on patients with comorbidities and use of prescription drugs after hospital discharge.
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Affiliation(s)
- Claire Zabawa
- Department of General Medicine, UFR Sciences de Santé
- Biostatistics and Bioinformatics, University Hospital
| | | | - Marianne Zeller
- Laboratory of Cardiometabolic Physiopathology and Pharmacology, INSERM U866, UFR Sciences de Santé, Bourgogne Franche-Comté University, Dijon
| | - Grégoire Mercier
- Economic Evaluation Unit, University Hospital, Montpellier, France
| | - Victor G. Rodwin
- Robert F. Wagner School of Public Service, New York University, New York, NY
| | - Yves Cottin
- Department of Cardiology, University Hospital
| | - Catherine Quantin
- Biostatistics and Bioinformatics, University Hospital
- INSERM, CIC 1432
- Clinical Epidemiology/Clinical Trials Unit, University Hospital, Clinical Investigation Center, Dijon
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases, INSERM, UVSQ, Institut Pasteur, Paris-Saclay University, Paris, France
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24
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Turk J, Fourny M, Yayehd K, Picard N, Ageron F, Boussat B, Belle L, Vanzetto G, Puymirat E, Labarère J, Debaty G. Age‐Related Differences in Reperfusion Therapy and Outcomes for ST‐Segment Elevation Myocardial Infarction. J Am Geriatr Soc 2018; 66:1325-1331. [DOI: 10.1111/jgs.15383] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Julien Turk
- Department of Emergency MedicineMétropole Savoie HospitalChambéry France
| | - Magali Fourny
- Quality of Care UnitGrenoble Alpes University HospitalGrenoble France
| | - Komlavi Yayehd
- Department of CardiologyAnnecy‐Genevois HospitalAnnecy France
| | - Nicolas Picard
- Department of Emergency MedicineMétropole Savoie HospitalChambéry France
| | | | - Bastien Boussat
- Quality of Care UnitGrenoble Alpes University HospitalGrenoble France
| | - Loïc Belle
- Department of CardiologyAnnecy‐Genevois HospitalAnnecy France
| | - Gérald Vanzetto
- Department of CardiologyGrenoble Alpes University HospitalGrenoble France
| | - Etienne Puymirat
- Department of Cardiology, Hôpital Européen Georges PompidouAssistance Publique‐Hôpitaux de Paris and Université Paris DescartesParis France
| | - José Labarère
- Quality of Care UnitGrenoble Alpes University HospitalGrenoble France
- Université Grenoble Alpes, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 5525, Techniques de l'Igénierie Médicale et de la Complexité ‐ Informatique, Mathématiques et Applications GrenobleGrenoble France
- Centre d'Investigation Clinique 1406, Institut National de la Santé et de la Recherche MédicaleGrenoble France
| | - Guillaume Debaty
- Centre d'Investigation Clinique 1406, Institut National de la Santé et de la Recherche MédicaleGrenoble France
- Department of Emergency MedicineGrenoble Alpes University HospitalGrenoble France
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25
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Clement G, Giovannelli J, Cottel D, Montaye M, Ciuchete A, Dallongeville J, Amouyel P, Dauchet L. Changes over time in the prevalence and treatment of cardiovascular risk factors, and contributions to time trends in coronary mortality over 25 years in the Lille urban area (northern France). Arch Cardiovasc Dis 2017; 110:689-699. [DOI: 10.1016/j.acvd.2017.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 02/28/2017] [Accepted: 03/14/2017] [Indexed: 11/30/2022]
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Abstract
BACKGROUND Patients over 75 account for more than one third of those presenting with myocardial infarction and more than 50% of intrahospital mortality. There are no specific guidelines for the management of acute coronary syndromes (ACS) in the elderly. SETTING Although antithrombotic therapy seems to be effective and safe in such patients, it requires specific precautions and treatment adjustments because of the higher bleeding risk due to comorbidities such as renal function impairment and malnutrition. RESULTS Scientific evidence concerning elderly patients is scarce as they are either excluded or underrepresented in most randomized trials. Overall, the antithrombotic therapy needs to be adapted to avoid complications, mainly bleeding complications, without compromising the effectiveness of the treatment in this high-risk population. CONCLUSION In the present paper, we review the current treatment strategies in ACS while focusing on data concerning the elderly, according to available data in pivotal trials and in both AHA/ACC and ESC guidelines.
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27
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Abstract
The clinical evidence for treatment of acute coronary syndrome (ACS) in the elderly is less robust than in patients younger than 75 years. The elderly have the highest incidence of cardiovascular disease and frequently present with ACS. This number can be expected to increase over time because society is aging. Older adults often sustain unfavorable outcomes from ACS because of atypical presentation and delay in recognition. In addition, elderly patients commonly do not receive optimal guideline-directed ACS treatment. Owing to their high baseline risk of ischemic complications, the elderly also fare worse even with optimal ACS treatment as they frequently have more complex coronary disease, more comorbidities, less cardiovascular reserve, and a higher risk of treatment complications. They are also subjected to a broader range of pharmacologic treatment. Treatment complications can be mitigated to some extent by meticulous dose adjustment of antithrombotic and adjunctive therapies. While careful transitions of care and appropriate utilization of post-discharge secondary preventive measures are important in ACS patients of all ages, the elderly are more vulnerable to system errors and thus deserve special attention from the clinician.
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Affiliation(s)
- Niels Engberding
- Department of Medicine, Division of Cardiology, National Jewish Health, Denver, Colorado, USA
| | - Nanette K Wenger
- Emory Heart and Vascular Center, Atlanta, Georgia, USA.,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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