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Kotanidis CP, Mills GB, Bendz B, Berg ES, Hildick-Smith D, Hirlekar G, Milasinovic D, Morici N, Myat A, Tegn N, Sanchis J, Savonitto S, De Servi S, Fox KAA, Pocock S, Kunadian V. Invasive vs. conservative management of older patients with non-ST-elevation acute coronary syndrome: individual patient data meta-analysis. Eur Heart J 2024; 45:2052-2062. [PMID: 38596853 PMCID: PMC11177715 DOI: 10.1093/eurheartj/ehae151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/30/2024] [Accepted: 02/28/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND AND AIMS Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) are less likely to receive guideline-recommended care including coronary angiography and revascularization. Evidence-based recommendations regarding interventional management strategies in this patient cohort are scarce. This meta-analysis aimed to assess the impact of routine invasive vs. conservative management of NSTEACS by using individual patient data (IPD) from all available randomized controlled trials (RCTs) including older patients. METHODS MEDLINE, Web of Science and Scopus were searched between 1 January 2010 and 11 September 2023. RCTs investigating routine invasive and conservative strategies in persons >70 years old with NSTEACS were included. Observational studies or trials involving populations outside the target range were excluded. The primary endpoint was a composite of all-cause mortality and myocardial infarction (MI) at 1 year. One-stage IPD meta-analyses were adopted by use of random-effects and fixed-effect Cox models. This meta-analysis is registered with PROSPERO (CRD42023379819). RESULTS Six eligible studies were identified including 1479 participants. The primary endpoint occurred in 181 of 736 (24.5%) participants in the invasive management group compared with 215 of 743 (28.9%) participants in the conservative management group with a hazard ratio (HR) from random-effects model of 0.87 (95% CI 0.63-1.22; P = .43). The hazard for MI at 1 year was significantly lower in the invasive group compared with the conservative group (HR from random-effects model 0.62, 95% CI 0.44-0.87; P = .006). Similar results were seen for urgent revascularization (HR from random-effects model 0.41, 95% CI 0.18-0.95; P = .037). There was no significant difference in mortality. CONCLUSIONS No evidence was found that routine invasive treatment for NSTEACS in older patients reduces the risk of a composite of all-cause mortality and MI within 1 year compared with conservative management. However, there is convincing evidence that invasive treatment significantly lowers the risk of repeat MI or urgent revascularisation. Further evidence is needed from ongoing larger clinical trials.
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Affiliation(s)
- Christos P Kotanidis
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, High Heaton NE7 7DN, United Kingdom
| | - Gregory B Mills
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, High Heaton NE7 7DN, United Kingdom
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erlend S Berg
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - David Hildick-Smith
- Sussex Cardiac Centre, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Geir Hirlekar
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dejan Milasinovic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | | | | | - Nicolai Tegn
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Juan Sanchis
- Department of Cardiology, Hospital Clinico Universitario, INCLIVA, Universitat de Valencia, CIBER-Cardiovascular, Valencia, Spain
| | | | - Stefano De Servi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, High Heaton NE7 7DN, United Kingdom
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2
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Roberts SM, Malhotra A, Cios TJ. Invasive Cardiac Therapies in Older People-Can We Raise the Bar? J Cardiothorac Vasc Anesth 2024; 38:1296-1298. [PMID: 38490901 DOI: 10.1053/j.jvca.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/17/2024]
Affiliation(s)
- S Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA.
| | - Anita Malhotra
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA
| | - Theodore J Cios
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA
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3
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Kelham M, Vyas R, Ramaseshan R, Rathod K, de Winter RJ, de Winter RW, Bendz B, Thiele H, Hirlekar G, Morici N, Myat A, Michalis LK, Sanchis J, Kunadian V, Berry C, Mathur A, Jones DA. Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management. Eur Heart J 2024:ehae245. [PMID: 38805681 DOI: 10.1093/eurheartj/ehae245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/20/2024] [Accepted: 04/07/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND AND AIMS A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. RESULTS Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5-10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97-1.29), cardiac mortality (RR 1.05, 95% CI 0.70-1.58), myocardial infarction (RR 0.90, 95% CI 0.65-1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78-1.40). CONCLUSIONS This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.
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Affiliation(s)
- Matthew Kelham
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rohan Vyas
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rohini Ramaseshan
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Krishnaraj Rathod
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Robbert J de Winter
- Department of Cardiology Heart Center, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bjorn Bendz
- Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Geir Hirlekar
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nuccia Morici
- IRCCS S. Maria Nascente-Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Aung Myat
- Medical Director (Cardiology), Medpace UK, London, UK
| | - Lampros K Michalis
- 2nd Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, University Campus, Ioannina 45110, Greece
| | - Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, INCLIVA University of València, CIBER CV, València, Spain
| | - Vijay Kunadian
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust and Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Colin Berry
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Anthony Mathur
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - Daniel A Jones
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
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Alonso Salinas GL, Cepas-Guillén P, León AM, Jiménez-Méndez C, Lozano-Vicario L, Martínez-Avial M, Díez-Villanueva P. The Impact of Geriatric Conditions in Elderly Patients with Coronary Heart Disease: A State-of-the-Art Review. J Clin Med 2024; 13:1891. [PMID: 38610656 PMCID: PMC11012545 DOI: 10.3390/jcm13071891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
The growing geriatric population presenting with coronary artery disease poses a primary challenge for healthcare services. This is a highly heterogeneous population, often underrepresented in studies and clinical trials, with distinctive characteristics that render them particularly vulnerable to standard management/approaches. In this review, we aim to summarize the available evidence on the treatment of acute coronary syndrome in the elderly. Additionally, we contextualize frailty, comorbidity, sarcopenia, and cognitive impairment, common in these patients, within the realm of coronary artery disease, proposing strategies for each case that may assist in therapeutic approaches.
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Affiliation(s)
- Gonzalo Luis Alonso Salinas
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain;
- Navarrabiomed (Miguel Servet Foundation), IdiSNA, 31008 Pamplona, Spain;
- Heath Sciences Department, Universidad Pública de Navarra (UPNA-NUP), 31006 Pamplona, Spain
| | - Pedro Cepas-Guillén
- Quebec Heart and Lung Institute, Laval University, 2725 Ch Ste-Foy, Quebec, QC G1V 4G5, Canada;
| | - Amaia Martínez León
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain;
- Navarrabiomed (Miguel Servet Foundation), IdiSNA, 31008 Pamplona, Spain;
| | - César Jiménez-Méndez
- Cardiology Department, Hospital Universitario Puerta del Mar, Avda Ana de Viya 21, 11009 Cádiz, Spain;
| | - Lucia Lozano-Vicario
- Navarrabiomed (Miguel Servet Foundation), IdiSNA, 31008 Pamplona, Spain;
- Geriatric Medicine Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain
| | - María Martínez-Avial
- Cardiology Department, Hospital Universitario La Princesa, Calle Diego de León 62, 28006 Madrid, Spain; (M.M.-A.); (P.D.-V.)
| | - Pablo Díez-Villanueva
- Cardiology Department, Hospital Universitario La Princesa, Calle Diego de León 62, 28006 Madrid, Spain; (M.M.-A.); (P.D.-V.)
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5
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Berg ES, Tegn NK, Abdelnoor M, Røysland K, Ryalen PC, Aaberge L, Eek C, Øie E, Juliebø V, Gjertsen E, Ranhoff AH, Gullestad L, Nordstrand N, Bendz B. Long-Term Outcomes of Invasive vs Conservative Strategies for Older Patients With Non-ST-Segment Elevation Acute Coronary Syndromes. J Am Coll Cardiol 2023; 82:2021-2030. [PMID: 37968019 DOI: 10.1016/j.jacc.2023.09.809] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is a frequent cause of hospital admission in older people, but clinical trials targeting this population are scarce. OBJECTIVES The After Eighty Study assessed the effect of an invasive vs a conservative treatment strategy in a very old population with NSTE-ACS. METHODS Between 2010 and 2014, the investigators randomized 457 patients with NSTE-ACS aged ≥80 years (mean age 85 years) to an invasive strategy involving early coronary angiography with immediate evaluation for revascularization and optimal medical therapy or to a conservative strategy (ie, optimal medical therapy). The primary endpoint was a composite of myocardial infarction, need for urgent revascularization, stroke, and death. The long-term outcomes are presented. RESULTS After a median follow up of 5.3 years, the invasive strategy was superior to the conservative strategy in the reduction of the primary endpoint (incidence rate ratio: 0.76; 95% CI: 0.63-0.93; P = 0.0057). The invasive strategy demonstrated a significant gain in event-free survival of 276 days (95% CI: 151-400 days; P = 0.0001) at 5 years and 337 days (95% CI: 123-550 days; P = 0.0001) at 10 years. These results were consistent across subgroups of patients with respect to major cardiovascular prognostic factors. CONCLUSIONS In patients aged ≥80 years with NSTE-ACS, the invasive strategy was superior to the conservative strategy in the reduction of composite events and demonstrated a significant gain in event-free survival. (The After Eighty Study: a randomized controlled trial; NCT01255540).
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Affiliation(s)
- Erlend S Berg
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nicolai K Tegn
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Michael Abdelnoor
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | | | | | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Christian Eek
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Erik Øie
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Vibeke Juliebø
- Department of Cardiology, Akershus University Hospital, Nordbyhagen, Norway
| | - Erik Gjertsen
- Department of Cardiology, Drammen Hospital, Drammen, Norway
| | | | | | - Njord Nordstrand
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
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Kalra K, Moumneh MB, Nanna MG, Damluji AA. Beyond MACE: a multidimensional approach to outcomes in clinical trials for older adults with stable ischemic heart disease. Front Cardiovasc Med 2023; 10:1276370. [PMID: 38045910 PMCID: PMC10690830 DOI: 10.3389/fcvm.2023.1276370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
The global population of older adults is expanding rapidly resulting in a shift towards managing multiple chronic diseases that coexist and may be exacerbated by cardiovascular illness. Stable ischemic heart disease (SIHD) is a predominant contributor to morbidity and mortality in the older adult population. Although results from clinical trials demonstrate that chronological age is a predictor of poor health outcomes, the current management approach remains suboptimal due to insufficient representation of older adults in randomized trials and the inadequate consideration for the interaction between biological aging, concurrent geriatric syndromes, and patient preferences. A shift towards a more patient-centered approach is necessary for appropriately and effectively managing SIHD in the older adult population. In this review, we aim to demonstrate the distinctive needs of older adults who prioritize holistic health outcomes like functional capacity, cognitive abilities, mental health, and quality of life alongside the prevention of major adverse cardiovascular outcomes reported in cardiovascular clinical trials. An individualized, patient-centered approach that involves shared decision-making regarding outcome prioritization is needed when any treatment strategy is being considered. By prioritizing patients and addressing their unique needs for successful aging, we can provide more effective care to a patient population that exhibits the highest cardiovascular risks.
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Affiliation(s)
- Kriti Kalra
- Inova Center of Outcomes Research, Inova Heart and Vascular, Fairfax, VA, United States
| | - Mohamad B. Moumneh
- Inova Center of Outcomes Research, Inova Heart and Vascular, Fairfax, VA, United States
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Abdulla A. Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular, Fairfax, VA, United States
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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van den Broek WWA, Gimbel ME, Chan Pin Yin DRPP, Azzahhafi J, Hermanides RS, Runnett C, Storey RF, Austin D, Oemrawsingh R, Cooke J, Galasko G, Walhout RJ, Schellings DAAM, Brinckman SL, The HK, Stoel MG, Heestermans AACM, Nicastia D, Emans ME, van ’t Hof AWJ, Alber H, Gerber R, van Bergen PFMM, Aksoy I, Nasser A, Knaapen P, Botman CJ, Liem A, Kelder JC, ten Berg JM. Conservative versus Invasive Strategy in Elderly Patients with Non-ST-Elevation Myocardial Infarction: Insights from the International POPular Age Registry. J Clin Med 2023; 12:5450. [PMID: 37685517 PMCID: PMC10487667 DOI: 10.3390/jcm12175450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
This registry assessed the impact of conservative and invasive strategies on major adverse clinical events (MACE) in elderly patients with non-ST-elevation myocardial infarction (NSTEMI). Patients aged ≥75 years with NSTEMI were prospectively registered from European centers and followed up for one year. Outcomes were compared between conservative and invasive groups in the overall population and a propensity score-matched (PSM) cohort. MACE included cardiovascular death, acute coronary syndrome, and stroke. The study included 1190 patients (median age 80 years, 43% female). CAG was performed in 67% (N = 798), with two-thirds undergoing revascularization. Conservatively treated patients had higher baseline risk. After propensity score matching, 319 patient pairs were successfully matched. MACE occurred more frequently in the conservative group (total population 20% vs. 12%, adjHR 0.53, 95% CI 0.37-0.77, p = 0.001), remaining significant in the PSM cohort (18% vs. 12%, adjHR 0.50, 95% CI 0.31-0.81, p = 0.004). In conclusion, an early invasive strategy was associated with benefits over conservative management in elderly patients with NSTEMI. Risk factors associated with ischemia and bleeding should guide strategy selection rather than solely relying on age.
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Affiliation(s)
- Wout W. A. van den Broek
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Marieke E. Gimbel
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Dean R. P. P. Chan Pin Yin
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Renicus S. Hermanides
- Department of Cardiology, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands;
| | - Craig Runnett
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, 8 Silver Fox Way, Newcastle upon Tyne NE27 0QJ, UK;
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2TN, UK;
| | - David Austin
- Academic Cardiovascular Unit, The James Cook University Hospital, Marton Rd., Middlesbrough TS4 3BW, UK;
| | - Rohit Oemrawsingh
- Department of Cardiology, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands;
| | - Justin Cooke
- Department of Cardiology, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield Rd., Calow, Chesterfield S44 5BL, UK;
| | - Gavin Galasko
- Department of Cardiology, Blackpool Teaching Hospital NHS Foundation Trust, Whinney Heys Rd., Blackpool FY3 8NR, UK;
| | - Ronald J. Walhout
- Department of Cardiology, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands;
| | - Dirk A. A. M. Schellings
- Department of Cardiology, Slingeland Hospital, Kruisbergseweg 25, 7009 BL Doetinchem, The Netherlands;
| | - Stijn L. Brinckman
- Department of Cardiology, Tergooi MC, Rijksstraatweg 1, 1261 AN Blaricum, The Netherlands;
| | - Hong Kie The
- Department of Cardiology, Treant Zorggroep, Boermarkeweg 60, 7824 AA Emmen, The Netherlands;
| | - Martin G. Stoel
- Department of Cardiology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, The Netherlands;
| | | | - Debby Nicastia
- Department of Cardiology, Gelre Hospital, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, The Netherlands;
| | - Mireille E. Emans
- Department of Cardiology, Ikazia Hospital, Montessoriweg 1, 3083 AN Rotterdam, The Netherlands;
| | - Arnoud W. J. van ’t Hof
- Department of Cardiology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands
| | - Hannes Alber
- Department for Internal Medicine and Cardiology, KABEG Klinikum, Feschnigstraße 11, 9020 Klagenfurt am Wörthersee, Austria;
| | - Robert Gerber
- Department of Cardiology, East Sussex Healthcare NHS Foundation Trust, Dane Rd., Seaford BN25 1DH, UK;
| | | | - Ismail Aksoy
- Department of Cardiology, Admiraal de Ruyter Hospital, ‘s-Gravenpolderseweg 114, 4462 RA Goes, The Netherlands;
| | - Abdul Nasser
- Department of Cardiology, South Tyneside and Sunderland NHS Foundation Trust, Harton Ln., South Shields NE34 0PL, UK;
| | - Paul Knaapen
- Department of Cardiology, Amsterdam University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Cees-Joost Botman
- Department of Cardiology, Sint Jans Gasthuis, Vogelsbleek 5, 6001 BE Weert, The Netherlands;
| | - Anho Liem
- Department of Cardiology, Franciscus Gasthuis, Kleiweg 500, 3045 PM Rotterdam, The Netherlands;
| | - Johannes C. Kelder
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Jurriën M. ten Berg
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
- Cardiovascular Research Institute Maastricht, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
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8
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Cacciatore S, Spadafora L, Bernardi M, Galli M, Betti M, Perone F, Nicolaio G, Marzetti E, Martone AM, Landi F, Asher E, Banach M, Hanon O, Biondi-Zoccai G, Sabouret P. Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence. J Clin Med 2023; 12:5233. [PMID: 37629275 PMCID: PMC10455820 DOI: 10.3390/jcm12165233] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.
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Affiliation(s)
- Stefano Cacciatore
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy
| | - Matteo Betti
- University of Milan, 20122, Milan, Italy
- Monzino IRCCS Cardiological Center, 20137 Milan, Italy
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic “Villa delle Magnolie”, 81020 Castel Morrone, Caserta, Italy
| | - Giulia Nicolaio
- Department of Experimental and Clinical Medicine and Geriatrics, University of Florence, Azienda Ospedaliero Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, 50134 Florence, Italy
| | - Emanuele Marzetti
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Anna Maria Martone
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Francesco Landi
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Elad Asher
- The Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, P.O. Box 12271, Jerusalem 9112102, Israel
| | - Maciej Banach
- Department of Preventive Cardiology, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Medical University of Lodz (MUL), 93-338 Lodz, Poland
| | - Olivier Hanon
- Assistance Publique Hôpitaux de Paris, Geriatric Department, Broca Hospital, University of Paris Cité, 54–56 Rue Pascal, 75013 Paris, France
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100 Latina, Italy
- Mediterranea Cardiocentro, Via Orazio 2, 80122 Naples, Italy
| | - Pierre Sabouret
- Heart Institute, Pitié-Salpétrière Hospital, ACTION-Group, Sorbonne University, 47–83 Bd de l’Hôpital, 75013 Paris, France
- Department of Cardiology, National College of French Cardiologists, 13 Rue Niépce, 75014 Paris, France
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9
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Balasubramanian RN, Mills GB, Wilkinson C, Mehran R, Kunadian V. Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes. Heart 2023; 109:504-510. [PMID: 36104217 DOI: 10.1136/heartjnl-2022-321470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/24/2022] [Indexed: 11/04/2022] Open
Abstract
We summarise the international guidelines surrounding risk stratification as well as discuss new emerging data for future development of a new risk model in the management of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS accounts for the bulk of acute coronary syndrome presentations in the UK, but management strategies in this group of patients have remained a subject of debate for decades. Patients with NSTE-ACS represent a heterogeneous population with a wide variation in short-term and long-term clinical outcomes, which makes a uniform, standardised treatment approach ineffective and inappropriate. Studies in the modern era have provided some guidance in treating this subset of patients: the provision of early, more potent therapies has been shown to improve outcomes in patients at a particularly elevated risk of adverse outcomes. International guidelines recommend adopting an individualised treatment approach through the use of validated risk prediction models to identify such patients at high risk of adverse outcomes. The present available evidence, however, is based on dated demographics, different diagnostic thresholds and outdated therapies. In particular, the evidence has limited applicability to female patients and older people with frailty. Moreover, the current risk models do not capture key prognostic variables, leading to an inaccurate estimation of patients' baseline risk and subsequent mistreatment. Therefore, the current risk models are no longer fit for purpose and there is a need for risk prediction scores that account for different population demographics, higher sensitivity troponin assays and contemporary treatment options.
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Affiliation(s)
| | - Greg B Mills
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Chris Wilkinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vijay Kunadian
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK .,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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10
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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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11
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De Servi S, Landi A, Savonitto S, De Luca L, De Luca G, Morici N, Montalto C, Crimi G, Cattaneo M. Tailoring oral antiplatelet therapy in acute coronary syndromes: from guidelines to clinical practice. J Cardiovasc Med (Hagerstown) 2023; 24:77-86. [PMID: 36583976 DOI: 10.2459/jcm.0000000000001399] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The assessment of bleeding and ischemic risk is a crucial step in establishing appropriate composition and duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS) treated with percutaneous coronary angioplasty. Evidence from recent randomized clinical trials led to some paradigm shifts in current guidelines recommendations. Options alternative to the standard 12-month DAPT duration include shorter periods of DAPT followed by single antiplatelet treatment with either aspirin or P2Y12 monotherapy, guided or unguided de-escalation DAPT, prolonged DAPT beyond the 12-month treatment period. Although DAPT composition and duration should be selected for each ACS patient on an individual basis weighing clinical and procedural variables, data from latest trials and meta-analyses may permit suggesting the most appropriate DAPT strategy according to the ischemic and bleeding risk assessed using validated tools and scores.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, Pavia, Italy
| | - Antonio Landi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | | | - Leonardo De Luca
- Department of Cardiovascular Sciences, A.O. San Camillo-Forlanini, Roma
| | - Giuseppe De Luca
- Clinical and Experimental Cardiology Unit, Azienda Ospedaliera-Universitaria di Sassari, University of Sassari, Sassari.,Clinical and Interventional Cardiology, Istituto Clinico Sant'Ambrogio, Gruppo San Donato
| | - Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS
| | - Claudio Montalto
- Interventional Cardiology, De Gasperis Cardio Center, Niguarda Hospital, Milan
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Genova
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12
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Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL, DeVon HA, Alexander KP. Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e32-e62. [PMID: 36503287 DOI: 10.1161/cir.0000000000001112] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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.
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13
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Cacciatore S, Martone AM, Landi F, Tosato M. Acute Coronary Syndrome in Older Adults: an Update from the 2022 Scientific Statement by the American Heart Association. HEART, VESSELS AND TRANSPLANTATION 2023. [DOI: 10.24969/hvt.2023.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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14
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Huang BT, Cheng YH, Yang BS, Zhang YK, Huang FY, Peng Y, Pu XB, Chen M. The influence of pressure injury risk on the association between left ventricular ejection fraction and all-cause mortality in patients with acute myocardial infarction 80 years or older. World J Emerg Med 2023; 14:112-121. [PMID: 36911061 PMCID: PMC9999128 DOI: 10.5847/wjem.j.1920-8642.2023.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/21/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND We aimed to investigate whether the pressure injury risk mediates the association of left ventricular ejection fraction (LVEF) with all-cause death in patients with acute myocardial infarction (AMI) aged 80 years or older. METHODS This retrospective cohort study included 677 patients with AMI aged 80 years or older from a tertiary-level hospital. Pressure injury risk was assessed using the Braden scale at admission, and three risk groups (low/minimal, intermediate, high) were defined according to the overall score of six different variables. LVEF was measured during the index hospitalization for AMI. All-cause death after hospital discharge was the primary outcome. RESULTS Over a median follow-up period of 1,176 d (interquartile range [IQR], 722-1,900 d), 226 (33.4%) patients died. Multivariate Cox regression analysis showed that reduced LVEF was associated with an increased risk of all-cause death only in the high-risk group of pressure injury (adjusted hazard ratios [HR]=1.81, 95% confidence interval [CI]: 1.03-3.20; P=0.040), but not in the low/minimal- (adjusted HR=1.29, 95%CI: 0.80-2.11; P=0.299) or intermediate-risk groups (adjusted HR=1.14, 95%CI: 0.65-2.02; P=0.651). Significant interactions were detected between pressure injury risk and LVEF (adjusted P=0.003). The cubic spline with hazard ratio plot revealed a distinct shaped curve relation between LVEF and all-cause death among different pressure injury risk groups. CONCLUSIONS In older patients with AMI, the risk of pressure injury mediated the association between LVEF and all-cause death. The classification of older patients for both therapy and prognosis assessment appears to be improved by the incorporation of pressure injury risk assessment into AMI care management.
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Affiliation(s)
- Bao-Tao Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yi-Heng Cheng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bo-Sen Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yi-Ke Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Fang-Yang Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xiao-Bo Pu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
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15
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Khalil M, Maqsood MH, Basir MB, Saad M, Yassa G, Hakam L, Abraham J, Hennawy BS, Etriby SE, Ribeiro MH, Ong K, Garcia S, Brilakis ES, Alaswad K, Megaly M. Meta-Analysis on Invasive Versus Conservative Strategy in Patients Older Than Seventy Years With Non-ST Elevation Myocardial Infarction. Am J Cardiol 2023; 186:66-70. [PMID: 36347067 DOI: 10.1016/j.amjcard.2022.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
Management of non-ST elevation myocardial infarction (NSTEMI) has evolved over the years, but most published data are from younger patients. Data on the NSTEMI management in older patients remain limited. We performed a meta-analysis of randomized controlled trials to evaluate the long-term outcomes of invasive versus conservative strategies in older patients (>70 years old) with NSTEMI. Of 1,550 reports searched, 4 randomized controlled trials (1,126 patients) were included in the analysis, with a median follow-up of 1.25 years (range: 1 to 2.5 years). The median age of included patients was 83.6 (interquartile range: 2.8 years). The invasive strategy was associated with significantly lower risk of major adverse cardiac and cerebrovascular event (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40 to 0.91, I2 = 54%; 3 trials] and unplanned revascularization (OR 0.31, 95% CI 0.15 to 0.64, I2 = 1.7%; 3 trials] than was the conservative strategy. There was no difference in all-cause mortality (OR 0.88, 95% CI 0.65 to 1.18, I2 = 0%; 4 trials], myocardial infarction (OR 0.70, 95% CI 0.42 to 1.19, I2 = 54.7%; 4 trials], or bleeding (OR 0.87, 95% CI 0.39 to 1.93, I2 = 0%; 3 trials] between the strategies. In conclusion, the use of initial invasive strategy in older patients presenting with NSTEMI was associated with a significantly lower risk of major adverse cardiac and cerebrovascular event and unplanned revascularization than that of the initial conservative strategy without increased bleeding.
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Affiliation(s)
| | | | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Marwan Saad
- Department of Cardiology, Brown University, Providence, Rhode Island
| | - George Yassa
- Department of Cardiology Ascension Macomb-Oakland, Warren, Michigan
| | - Laila Hakam
- Internal Medicine Department, Mayo Clinic, Jacksonville, Florida
| | - Joseph Abraham
- Department of Cardiology Unity Health White County Medical Center, Searcy, Arkansas
| | | | | | | | - Kenneth Ong
- Cardiovascular Medicine, Lincoln Medical Center, New York City, New York
| | - Santiago Garcia
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Michael Megaly
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan.
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16
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Matthews CJ, Kirby J, Blaxill JM, Greenwood JP, Mozid AM, Rossington JA, Veerasamy M, Wassef N, Wheatcroft SB, Bulluck H. Management of non-ST-segment elevation myocardial infarction in patients aged ≥ 80 years: a meta-analysis of randomized controlled trials. J Geriatr Cardiol 2022; 19:789-790. [PMID: 36338285 PMCID: PMC9618845 DOI: 10.11909/j.issn.1671-5411.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Affiliation(s)
- Connor J Matthews
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Joshua Kirby
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Jonathan M Blaxill
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - John P Greenwood
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Abdul M Mozid
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Jennifer A Rossington
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Murugapathy Veerasamy
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Nancy Wassef
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Stephen B Wheatcroft
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Heerajnarain Bulluck
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
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17
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Abusnina W, Radaideh Q, Al-Abdouh A, Ismayl M, Algheriani H, Lee J, Alam M, Ben-Dor I, Jimenez E, Azrin M, Paul TK, Dahal K. Routine Invasive Strategy in Elderly Patients with Non-ST Elevation Acute Coronary Syndrome: An Updated Systematic Review and Meta-analysis of Randomized Trials. Curr Probl Cardiol 2022; 47:101304. [PMID: 35803333 DOI: 10.1016/j.cpcardiol.2022.101304] [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: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Invasive treatment with coronary angiography is preferred approach for patients with non-ST elevation acute coronary syndrome (NSTE-ACS) compared to medical therapy alone. The results from the randomized clinical trials (RCT) that compared the invasive treatment strategy vs. conservative approach in the elderly (≥75 years) with NSTE-ACS has been inconsistent. AIM To compare invasive and conservative strategies in the elderly (>75 years) with NSTE-ACS. METHODS AND RESULTS We searched PubMed, Cochrane CENTRAL Register and ClinicalTrials.gov (inception through July 10, 2021) for RCTs comparing invasive and conservative strategies in the elderly with NSTE-ACS. We used random-effects model to calculate risk ratio (RR) with 95% confidence interval(CI). A total of 6 RCT including 2,323 patients were included in the meta-analysis. The median follow-up duration was 13.5 months. When invasive approach was compared to conservative strategy, it showed no difference in all-cause mortality in patients aged ≥75 years with NSTE-ACS (RR of 0.85; 95% CI 0.70-1.04; P = 0.12; I2 = 0%). There was significant reduction in MI (RR 0.59; 95% CI 0.49 0.71; P < 0.001; I2 = 0%) and unplanned revascularization (RR 0.30, 95% CI 0.17-0.53, P <0.001, I2 = 0%). Invasive strategy was associated with higher risk of major bleeding when compared to conservative treatment (RR 2.12, 95% CI 1.21-3.74, P=0.009, I2 = 0%). Comparison of both strategies showed no significant difference in stroke (RR 0.75; 95% CI 0.38-1.46, P = 0.40; I2 = 0%). CONCLUSION This updated meta-analysis suggests that in elderly patients (>75 years) with NSTE-ACS, a routine invasive strategy is associated with a reduction in MI and revascularization, while increasing the risk of major bleeding, but without difference in all-cause mortality and stroke.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE.
| | - Qais Radaideh
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
| | - Ahmad Al-Abdouh
- Department of Medicine, University of Kentucky, Lexington, KY
| | - Mahmoud Ismayl
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
| | | | - Juyong Lee
- Division of interventional cardiology, University of Connecticut Health Center, Farmington, CT
| | - Mahboob Alam
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington DC
| | - Enrique Jimenez
- Section of Cardiology, Overton Brooks Veterans Affairs Medical Center, Shreveport, LA
| | - Michael Azrin
- Division of interventional cardiology, University of Connecticut Health Center, Farmington, CT
| | - Timir K Paul
- Department of medical education, University of Tennessee at Nashville, Nashville, TN
| | - Khagendra Dahal
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
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18
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Zhang D, Xing YL, Wang H, Wang S, Miao Y, Huang W, Zhang K, Li HW, Sun Y, Chen H. Invasive treatment strategy in patients aged 80 years or older with non-ST-elevation acute coronary syndromes: a retrospective cohort study. Cardiovasc Diagn Ther 2022; 12:229-240. [PMID: 35433346 PMCID: PMC9011088 DOI: 10.21037/cdt-21-650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Invasive treatment is commonly recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, the efficacy of this approach in patients aged ≥80 years remains uncertain. METHODS We retrospectively assessed consecutive NSTE-ACS patients ≥80 years of age who were hospitalized at our cardiovascular center from December 2012 to July 2019. Patients were divided into two groups based on whether they received invasive treatment (coronary angiography and, if indicated, revascularization) or not. Patients who died in the first 3 days after admission without receiving invasive treatment were excluded. The effect of invasive timed treatment was also explored by dividing patients into timely invasive or delayed invasive groups according to their risk classification. Multivariate COX regression, invasive probability weighting and propensity score matching were used to adjust for confounding variables. The primary outcome was all-cause death during follow-up. RESULTS A total of 1,201 patients with a median age of 82.0 (IQR, 81.0-84.0) were divided into two groups: 656 (54.6%) patients in the invasive group and 545 (45.4%) patients in the conservative group. Follow-up survival information was available for up to 6 years (median 3.0 years). During the follow-up, 296 (24.6%) patients died. After adjusting for confounding variables, the invasive treatment strategy was significantly associated with a lower risk of long-term mortality (HR =0.70, 95% CI: 0.54-0.92, P=0.010). No difference was found between timely invasive and delayed invasive interventions with mortality (HR =0.92, 95% CI: 0.57-1.47, P=0.725). CONCLUSIONS Invasive treatment was associated with lower mortality in patients ≥80 years of age with NSTE-ACS over a median of a 3-year follow-up. The invasive intervention time did not impact the outcome.
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Affiliation(s)
- Dai Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yun-Li Xing
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Huan Wang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shan Wang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ye Miao
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Huang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Kan Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hong-Wei Li
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ying Sun
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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19
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Abusnina W, Alam M, Dahal K. Meta-Analysis Comparing Outcomes of Invasive Versus Conservative Strategy in Octogenarians With Non-ST Segment Elevation Acute Myocardial Infarction. Am J Cardiol 2021; 160:130-132. [PMID: 34740392 DOI: 10.1016/j.amjcard.2021.08.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/24/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Waiel Abusnina
- Division of Cardiology, Creighton University, Omaha, Nebraska.
| | - Mahboob Alam
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Khagendra Dahal
- Division of Cardiology, Creighton University, Omaha, Nebraska
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20
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Coronary stent fracture in an octogenarian patient: from bad to worse. J Geriatr Cardiol 2021; 18:968-972. [PMID: 34908931 PMCID: PMC8648541 DOI: 10.11909/j.issn.1671-5411.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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21
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Wang H, Shi L, Tian W, Zhao S. Invasive versus conservative strategy in the very elderly with non-ST-elevation acute coronary syndrome: A meta-analysis of randomized controlled trials. Geriatr Gerontol Int 2021; 22:36-41. [PMID: 34796611 DOI: 10.1111/ggi.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 11/30/2022]
Abstract
AIM To investigate the optimal treatment strategy in patients older than 80 years with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). METHODS All published randomized, placebo-controlled trials (RCTs) reporting on comparisons between invasive and conservative strategies for patients aged 80 years or older with NSTE-ACS were identified. The literature search was performed using PubMed, EMBASE, Cochrane Library, and the ISI Web of Science, from their establishment to July 2021 with no language restriction. The pooled risk ratios (RRs) with 95% confidence intervals (CI) for dichotomous outcomes were calculated. RESULTS Three RCTs involving a total of 893 cases met the inclusion criteria. Compared with the conservative group, the invasive strategy could significantly improve the incidence rate of composite endpoint (I2 = 21.9%; RR 0.727, 95% CI 0.619 to 0.855, P < 0.001), recurrent myocardial infarction (MI) (I2 = 0.0%; RR 0.585, 95% CI 0.441 to 0.776, P < 0.001) and revascularization (I2 = 0.0%; RR 0.239, 95% CI 0.126 to 0.455, P < 0.001). However, no benefits were observed on outcomes of all-cause death (I2 = 0.0%; RR 0.888, 95% CI 0.681 to 1.160, P = 0.384), cardiac death (I2 = 0.0%; RR 0.769, 95% CI 0.412 to 1.433, P = 0.408) and stroke (I2 = 0.0%; RR 0.778, 95% CI 0.392 to 1.543, P = 0.473). The major bleeding events were comparable between the two groups (I2 = 0.0%; RR 1.582, 95% CI 0.622 to 4.025, P = 0.336). CONCLUSIONS Compared with a conservative strategy, the invasive treatment could reduce the incidence of composite endpoint, recurrent MI, and revascularization in the very elderly with NSTE-ACS. However, no benefits were observed on mortality. Geriatr Gerontol Int 2021; ••: ••-••.
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Affiliation(s)
- Haiyan Wang
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Liye Shi
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Wen Tian
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Shijie Zhao
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
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22
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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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Savonitto S, De Servi S. Early invasive approach and outcome in elderly patients with NSTEACS: randomised trials, real-world data and guideline recommendations. EUROINTERVENTION 2021; 17:20-21. [PMID: 33998526 PMCID: PMC9707460 DOI: 10.4244/eijv17i1a4] [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: 11/23/2022]
Affiliation(s)
- Stefano Savonitto
- Dipartimento Cardiovascolare, Ospedale A. Manzoni, Via dell’Eremo, 9, 23900 Lecco, Italy
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