A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients

Cardiology and Therapy, Sep 2015

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.

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A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients

To view enhanced content go to www.cardiologytherapy-open.com 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 - 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)


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Claire McCune, Peter McKavanagh, Ian. B. Menown. A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients, Cardiology and Therapy, 2015, pp. 95-116, Volume 4, Issue 2, DOI: 10.1007/s40119-015-0047-x