A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients
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Received: June
A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients
Claire McCune . Peter McKavanagh . Ian. B. Menown 0
0 C. McCune (&) P. McKavanagh Ian. B. Menown Craigavon Cardiac Centre, Southern Trust , Craigavon, Northern Ireland BT63 5QQ , UK
The elderly constitute a sizeable proportion of the acute coronary syndrome (ACS) population, and this population is continually increasing in number. Guideline-directed therapy is frequently underutilized in the elderly due to concerns about patient safety. However, studies suggest that this subgroup could benefit from many of the conventional and newer therapies available. This paper reviews current literature in the context of contemporary American and European guidance.
ACE inhibitors; Acute coronary syndrome; Angiotensin receptor blockers; Antiplatelet therapy; Elderly; Heart failure; Non ST elevation acute coronary syndrome; Revascularization; Statins; Very elderly
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The elderly constitute a significant portion of
the acute coronary syndrome (ACS) population,
with over 75 year olds representing 27–34 % in
European registries [1]. Furthermore, aging
patients are an increasing cohort, with over
85 year olds expected to triple by the year 2035
[2]. This changing epidemiology presents new
difficulties in diagnostic and management
strategies. Cardiovascular medicine is a
continually evolving and progressive
discipline. However, elderly patients are
frequently under-represented in clinical trials,
leading to uncertainty among clinicians about
the relative efficacy and safety of some
treatments in this group and, as a
consequence, they are less likely to receive
evidence-based therapies [3].
Although at higher baseline risk, this
contributes further to the poorer outcomes in
elderly patients compared with younger patient
groups [4]. This paper aims to review and
summarize the latest evidence and guidelines
relevant to managing elderly patients, with
discussion of current patterns of practice and the
obstacles to delivering guideline-directed care.
This article is based on previously conducted
studies and does not involve any new studies of
human or animal subjects performed by any of
the authors.
CLINICAL CHARACTERISTICS
OF ELDERLY PATIENTS WITH ACS
Mehta et al. analyzed 163,140 hospital
admissions of Medicare beneficiaries age C65
admitted from 1994 to 1996 and subcategorized
these patients by age [5]. Increasing age was
associated with a greater incidence of functional
limitations, heart failure, prior coronary disease,
and renal insufficiency [5]. Conversely, there is
less diabetes and fewer male patients in older
subgroups [5].
Through analysis of five nationwide Italian
registries, De Luca et al. demonstrated the
changing characteristics of the elderly cohort
([75 years of age) admitted to coronary care
units with an acute myocardial infarction over
time from 2001 to 2010 [6]. This showed
increased hypertension, renal dysfunction, and
previous PCI but reduced history of previous
stroke, myocardial infarction, or heart failure
compared to earlier cohorts [6].
DIAGNOSIS AND INITIAL
TREATMENT
Recognition of ACS can be difficult in older
patient groups. This is due a combination of
patient factors with multiple barriers to
diagnosis, but also due to inadequacies in
service provision. Elderly patient groups are
less likely to call emergency services or make
their own way to hospital, and patients aged
over 65 who do contact emergency services
were found to be given a lower priority than
patients aged 51–64 years old [7, 8]. The joint
American Colleges of the American Heart
Association and American College of
Cardiology (AHA/ACC) as well as the
European Society of Cardiology (ESC)
guidelines state that the initial ECG should be
taken within 10 min [9, 10]. However, the
CRUSADE (Can Rapid Risk Stratification of
Unstable Angina Patients Suppress ADverse
Outcomes with Early Implementation of the
ACC/AHA Guidelines) registry highlighted that
elderly patients ([85) on average wait an
additional 7 min before receiving an initial
ECG, and women over 85 were shown to wait
for an average of 45 min [4, 11].
Diagnosis is further delayed by the atypical
presentation of elderly patients as found by the
GRACE (Global Registry of Acute Coronary
Events) registry [12]. Atypical symptoms
included dyspnea in 49%, diaphoresis in 26 %,
nausea or vomiting in 24%, and syncope in 19%
(Fig. 1) [12]. Other confounders to diagnosis
found more frequently in these patients include
Fig. 1 Elderly patients often present with atypical
symptoms other than chest pain
silent myocardial infarctions, which account for
up to 60% of infarcts in patients over 85 years
old, and concurrent illnesses such as
pneumonia [4].
Inequalities in care were also found on
admission, with elderly patients less likely to
be admitted to a cardiology ward or under the
care of a consultant (...truncated)