Unstable angina / non ST elevation myocardial infarction and the elderly
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Resident Survival Guide |
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Unstable angina / NSTEMI Microchapters |
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Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
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Diagnosis |
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Antitplatelet Therapy |
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Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
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Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Smita Kohli, M.D.
Overview
Elderly patients represent a group of patients who have more comorbidities and who are both at risk for both CAD as well as for associated complications. However, they do derive equivalent or greater benefit from intervention when compared to younger patients. This group is likely to present with atypical symptoms like dyspnea and confusion rather than chest pain. On the other hand, presence of noncardiac comorbidities such as chronic obstructive lung disease, gastroesophageal reflux disease, upper-body musculoskeletal symptoms, pulmonary embolism, and pneumonia is also higher, thus making the diagnosis of UA/NSTEMI challenging. Secondly, they are more likely to have altered or abnormal cardiovascular anatomy, increased cardiac afterload due to decreased arterial compliance and arterial hypertension, orthostatic hypotension, cardiac hypertrophy, and ventricular dysfunction, especially diastolic dysfunction. Thirdly, elderly patients generally have other cardiac comorbidities and risk factors, such as hypertension, prior MI, HF, cardiac conduction abnormalities, prior CABG, peripheral and cerebrovascular disease, diabetes mellitus, renal insufficiency, and stroke. As a result, they are on mulitple medications and hence at risk for drug interactions and polypharmacy. When considering revascularization procedures, general medical and cognitive status, bleeding risk and other risk of interventions, anticipated life expectancy, and patient or family preferences must be considered.
Pharmacological Management
- Recent studies have documented that this group of patients less often receive evidence based pharmacotherapy and less use of aggressive approach.
- Precautions need to be taken to adjust dosage according to age and renal function. They also typically have lower body mass and hence lower drug distribution volumes. Elderly patients are frequently overdosed as shown in recent studies.
- Risk of bleeding is also higher in this subgroup.
However, current evidence does show that in spite of an increasing number of possible relative contraindications associated with older age, the rates of serious adverse events for most older patients generally remain low when evidence based treatment for UA/NSTEMI is provided.
Revascularization in Elderly Patients
A meta-analysis of recently published PCI trials[1] has demonstrated a clear benefit of PCI in older patients.
- These trials indicated that compared with younger patients, the elderly gain important absolute benefits from an early invasive strategy but at a cost of increased bleeding.
- Specifically, a significant benefit was seen in reduction of the combined end point of death and recurrent MI, but only a trend to reduction in death was noted.
However, selection of these patients for PCI can be challenging and should include weighing risk from disease against risk from intervention. Despite of clear benefit of PCI in this population, this strategy remains underused which may be due to practitioner concerns about the increased risk of complications.
With appropriate selection of patients, even CABG remains an option for this subgroup of patients and studies have shown benefit from CABG even in the oldest patient subgroups.
Predictors of operative death (LV dysfunction, previous CABG, peripheral vascular disease, and diabetes) are generally similar to those in younger patients.
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [2]
NSTE-ACS in Older Patients
| Class I |
| "1. Older patients with NSTE-ACS should be treated with GDMT, an early invasive strategy, and revascularization as appropriate. (Level of Evidence: A)" |
| "2. Pharmacotherapy in older patients with NSTE-ACS should be individualized and dose adjusted by weight and/or CrCl to reduce adverse events caused by age-related changes in pharmacokinetics/dynamics, volume of distribution, comorbidities, drug interactions, and increased drug sensitivity. (Level of Evidence: A)" |
| "3. Management decisions for older patients with NSTE-ACS should be patient centered, and consider patient preferences/goals, comorbidities, functional and cognitive status, and life expectancy. (Level of Evidence: B)" |
| Class IIa |
| "1. Bivalirudin, rather than a GP IIb/IIIa inhibitor plus UFH, is reasonable in older patients with NSTE-ACS, both initially and at PCI, given similar efficacy but less bleeding risk. (Level of Evidence: B)" |
| "2. It is reasonable to choose CABG over PCI in older patients**with NSTE-ACS who are appropriate candidates, particularly those with diabetes mellitus or complex 3-vessel CAD (e.g., SYNTAX score >22), with or without involvement of the proximal LAD artery, to reduce cardiovascular disease events and readmission and to improve survival. (Level of Evidence: B)" |
2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)[3]
Older Adults (DO NOT EDIT)[3]
| Class I |
| "1. Older patients with UA/NSTEMI should be evaluated for appropriate acute and long term therapeutic interventions in a similar manner as younger patients with UA/NSTEMI. (Level of Evidence: A)" |
| "2. Decisions on management of older patients with UA / NSTEMI should not be based solely on chronologic age but should be patient centered, with consideration given to general health, functional and cognitive status, comorbidities, life expectancy, and patient preferences and goals. (Level of Evidence: B)" |
| "3. Attention should be given to appropriate dosing (i.e., adjusted by weight and estimated creatinine clearance) of pharmacological agents in older patients with UA/NSTEMI, because they often have altered pharmacokinetics (due to reduced muscle mass, renal and/or hepatic dysfunction, and reduced volume of distribution) and pharmacodynamics (increased risks of hypotension and bleeding). (Level of Evidence: B)" |
| "4. Older UA/NSTEMI patients face increased early procedural risks with revascularization relative to younger patients, yet the overall benefits from invasive strategies are equal to or perhaps greater in older adults and are recommended. (Level of Evidence: B)" |
| "5. Consideration should be given to patient and family preferences, quality of life issues, end of life preferences, and sociocultural differences in older patients with UA/NSTEMI. (Level of Evidence: C)" |
References
- ↑ Mehta SR, Cannon CP, Fox KA; et al. (2005). "Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials". JAMA. 293 (23): 2908–17. doi:10.1001/jama.293.23.2908. PMID 15956636. Unknown parameter
|month=ignored (help) - ↑ Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
- ↑ 3.0 3.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888.