Acute Coronary Syndrome Management in Older Adults
Acute Coronary Syndrome Management in Older Adults
Management of ACS in older adults remains a clinical challenge despite guidelines outlining care pathways. The ageing population means the burden of ACS will increase particularly in older adults. Trial evidence ( Table 1 ) and epidemiological data indicate the benefit of an early evidence-based approach. Temporal improvements in the delivery of ACS care in older adults have been documented but disparities continue to exist, which indicates that there is still scope to improve outcomes.
The impact of the physiology of ageing on an individual may be difficult to assess quickly in an acute setting such as an ACS. The clinical relevance of altered drug metabolism is uncertain, especially between individuals. Difficulties with immediate pharmacotherapy decisions and perhaps a reluctance of physicians to prescribe medications with potential adverse effects are an area of concern. There may be a reluctance to prescribe some medications such as beta-blockers due to concerns over efficacy and the potential for worsening cardiac output. The controlled environment of a hospital ward should allow these medications to be administered and any adverse effects promptly treated. The degree of polypharmacy and renal handling issues could be addressed by early involvement of pharmacists and elderly care physicians to rationalize medications and ensure correct dosing regimens. This strategy is particularly important in the management of ACS as providing a guideline-based approach may potentially contribute to polypharmacy. Therefore, rationalising medications, particularly stopping drugs with limited prognostic benefit, could improve adherence to guidelines. Some classes of drugs, for example, statins, may also be indicated for several conditions given the prevalence of other vascular disease in individuals with CAD. There is evidence that currently these are under prescribed in the elderly.. Medications such as ACE-inhibitors could be withheld until after intervention in order to minimise the risk of contrast nephropathy. There is a need to carefully dose drugs such as low-molecular-weight heparins and glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors to minimise bleeding risk.
Recognition of ACS has also been highlighted as a significant area of concern. The prevalence of atypical presentation and non-diagnostic ECGs are non-modifiable and will lead to delays in diagnosis and treatment. Therefore, clinicians need a high index of suspicion of ACS and refer early for specialist opinion. This will enable timely provision of guideline-based therapies. However, ascertaining the relevance of raised cardiac biomarkers in elderly individuals with the presence of a concurrent acute illness and no other features of AMI remains challenging.
The burden of co-morbidities also presents difficulties in the provision of evidence-based care. Higher rates of anaemia and renal disease need consideration before exposure to a procedure with potential side-effects of bleeding and further renal impairment. This may lead to further delay in appropriate treatment. Vascular access sites should be carefully considered as part of the risk assessment before considering an invasive strategy as the elderly are more likely to have calcified and tortuous great vessel anatomy with increased bleeding risk. The extent of intervention may also be an issue due to the increased prevalence of multi-vessel and complex disease that is evident following angiography. Clinicians may therefore adopt a 'first, do no harm' approach. Procedural consent may be more difficult with higher rates of dementia, hearing and visual impairment.
These concerns are justified but the epidemiological data show us improved outcomes in older adults despite the greater burden of co-morbidities. Perhaps greater utilisation of risk scores can aid this decision process. We know that risk scores are currently poorly implemented in clinical practice and that older adults are often subjectively assigned to lower risk groups. This potentially has huge implications on subsequent management and means they are less likely to receive interventional therapies. Further evaluation is needed to validate frailty risk scores, which assess different factors to traditional risk scoring systems, to determine whether they help identify which of this high-risk group have the most to gain from an interventional approach. Using verified bleeding scores such as CRUSADE can provide objective data of potential harm to enable clinicians to make balanced objective risk–benefit decisions. Clearly, an interventional treatment strategy is not in every patient's interests and therefore use of risk scoring systems may help identify these individuals. Its important to take into account patient preferences and objective data can aid both clinicians and patients during the consent process.
There is a need for RCTs to more accurately reflect the population and not only consider procedural efficacy and safety but the longer term effectiveness of revascularisation in older adults. Numerous previous authors have suggested this solution and there has been minimal improvement in the proportion of older adults in trial populations. The large costs involved in setting up clinical trials and a lack of understanding of the heterogeneity of the ageing process means this is unlikely to change in the future. However, the looming explosion in the elderly population mean gathering evidence for ACS management is vital. Alternative approaches such as those employed in trial-registries like the Thrombus Aspiration in STEMI in Scandinavia (TASTE) trial based on the Swedish angiography and angioplasty registry (SCAAR) platform may be beneficial.
Access to specialist cardiologist facilities remains an area of concern. Elderly patients who are not under the care of a specialist have delays to diagnosis and the provision of guideline recommended therapy, and less access to interventional strategies. The reasons for this are not clear but may include a desire by the admitting physician to preferentially treat those who are younger because this group is perceived to have more to lose in the longer term. Longer length of stays for elderly patients will become a larger concern in the future and may have significant impacts on availability of coronary care beds and health economics. Development of an elderly cardiac team, encompassing cardiologists, elderly care physicians and rehabilitation teams could ensure those with the greatest potential benefit have access to interventional services as well as reducing hospital stays.
Further research in to post-AMI management strategies in elderly patients could help improve outcomes in conjunction with greater utilisation of cardiac rehabilitation. Longer term the development of an ACS guideline for older adults, similar to NICE hip fracture guidelines, could enable a more co-ordinated approach to both delivering immediate ACS care and ongoing post AMI management.
Discussion
Management of ACS in older adults remains a clinical challenge despite guidelines outlining care pathways. The ageing population means the burden of ACS will increase particularly in older adults. Trial evidence ( Table 1 ) and epidemiological data indicate the benefit of an early evidence-based approach. Temporal improvements in the delivery of ACS care in older adults have been documented but disparities continue to exist, which indicates that there is still scope to improve outcomes.
The impact of the physiology of ageing on an individual may be difficult to assess quickly in an acute setting such as an ACS. The clinical relevance of altered drug metabolism is uncertain, especially between individuals. Difficulties with immediate pharmacotherapy decisions and perhaps a reluctance of physicians to prescribe medications with potential adverse effects are an area of concern. There may be a reluctance to prescribe some medications such as beta-blockers due to concerns over efficacy and the potential for worsening cardiac output. The controlled environment of a hospital ward should allow these medications to be administered and any adverse effects promptly treated. The degree of polypharmacy and renal handling issues could be addressed by early involvement of pharmacists and elderly care physicians to rationalize medications and ensure correct dosing regimens. This strategy is particularly important in the management of ACS as providing a guideline-based approach may potentially contribute to polypharmacy. Therefore, rationalising medications, particularly stopping drugs with limited prognostic benefit, could improve adherence to guidelines. Some classes of drugs, for example, statins, may also be indicated for several conditions given the prevalence of other vascular disease in individuals with CAD. There is evidence that currently these are under prescribed in the elderly.. Medications such as ACE-inhibitors could be withheld until after intervention in order to minimise the risk of contrast nephropathy. There is a need to carefully dose drugs such as low-molecular-weight heparins and glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors to minimise bleeding risk.
Recognition of ACS has also been highlighted as a significant area of concern. The prevalence of atypical presentation and non-diagnostic ECGs are non-modifiable and will lead to delays in diagnosis and treatment. Therefore, clinicians need a high index of suspicion of ACS and refer early for specialist opinion. This will enable timely provision of guideline-based therapies. However, ascertaining the relevance of raised cardiac biomarkers in elderly individuals with the presence of a concurrent acute illness and no other features of AMI remains challenging.
The burden of co-morbidities also presents difficulties in the provision of evidence-based care. Higher rates of anaemia and renal disease need consideration before exposure to a procedure with potential side-effects of bleeding and further renal impairment. This may lead to further delay in appropriate treatment. Vascular access sites should be carefully considered as part of the risk assessment before considering an invasive strategy as the elderly are more likely to have calcified and tortuous great vessel anatomy with increased bleeding risk. The extent of intervention may also be an issue due to the increased prevalence of multi-vessel and complex disease that is evident following angiography. Clinicians may therefore adopt a 'first, do no harm' approach. Procedural consent may be more difficult with higher rates of dementia, hearing and visual impairment.
These concerns are justified but the epidemiological data show us improved outcomes in older adults despite the greater burden of co-morbidities. Perhaps greater utilisation of risk scores can aid this decision process. We know that risk scores are currently poorly implemented in clinical practice and that older adults are often subjectively assigned to lower risk groups. This potentially has huge implications on subsequent management and means they are less likely to receive interventional therapies. Further evaluation is needed to validate frailty risk scores, which assess different factors to traditional risk scoring systems, to determine whether they help identify which of this high-risk group have the most to gain from an interventional approach. Using verified bleeding scores such as CRUSADE can provide objective data of potential harm to enable clinicians to make balanced objective risk–benefit decisions. Clearly, an interventional treatment strategy is not in every patient's interests and therefore use of risk scoring systems may help identify these individuals. Its important to take into account patient preferences and objective data can aid both clinicians and patients during the consent process.
There is a need for RCTs to more accurately reflect the population and not only consider procedural efficacy and safety but the longer term effectiveness of revascularisation in older adults. Numerous previous authors have suggested this solution and there has been minimal improvement in the proportion of older adults in trial populations. The large costs involved in setting up clinical trials and a lack of understanding of the heterogeneity of the ageing process means this is unlikely to change in the future. However, the looming explosion in the elderly population mean gathering evidence for ACS management is vital. Alternative approaches such as those employed in trial-registries like the Thrombus Aspiration in STEMI in Scandinavia (TASTE) trial based on the Swedish angiography and angioplasty registry (SCAAR) platform may be beneficial.
Access to specialist cardiologist facilities remains an area of concern. Elderly patients who are not under the care of a specialist have delays to diagnosis and the provision of guideline recommended therapy, and less access to interventional strategies. The reasons for this are not clear but may include a desire by the admitting physician to preferentially treat those who are younger because this group is perceived to have more to lose in the longer term. Longer length of stays for elderly patients will become a larger concern in the future and may have significant impacts on availability of coronary care beds and health economics. Development of an elderly cardiac team, encompassing cardiologists, elderly care physicians and rehabilitation teams could ensure those with the greatest potential benefit have access to interventional services as well as reducing hospital stays.
Further research in to post-AMI management strategies in elderly patients could help improve outcomes in conjunction with greater utilisation of cardiac rehabilitation. Longer term the development of an ACS guideline for older adults, similar to NICE hip fracture guidelines, could enable a more co-ordinated approach to both delivering immediate ACS care and ongoing post AMI management.
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