Acute coronary syndromes in older patients: does older age matter?
Authors: Bjørn Bendz, Lars Aaberge
Journal: The Lancet (2020)

Ischaemic heart disease is common in people aged 80 years or older, and is a major cause of morbidity and mortality in this age group worldwide. As this patient group grows, with an increase in life expectancy of up to 10 years or more, the absolute prevalence of cardiovascular disease is expected to increase. 1 Jaguszewski M Ghadri JR Diekmann J et al. Acute coronary syndromes in octogenarians referred for invasive evaluation: treatment profile and outcomes. Clin Res Cardiol. 2015; 104: 51-58 Crossref PubMed Scopus (17) Google Scholar According to present guidelines, medical optimisation followed by an invasive strategy—including coronary angiography and subsequent revascularisation with percutaneous coronary intervention or coronary artery bypass graft—is recommended for eligible patients with acute coronary syndromes without ST-segment elevation (NSTE-ACS). 2 Roffi M Patrono C Collet J-P et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016; 37: 267-315 Crossref PubMed Scopus (4344) Google Scholar However, these recommendations are not age-specific and have been based on registry studies, underpowered studies, or randomised trials of patients with mean age of around 65 years. People aged 80 years or older are characterised by heterogeneity and a higher occurrence of comorbidities, polypharmacy, physical frailty, and cognitive decline. They also seem to have substantially more complex coronary anatomy with serious calcifications, tortuosity, ostial lesions, and multivessel and left main stenoses, suggesting that they might achieve a greater benefit from coronary revascularisation therapy. 3 Shanmugam VB Harper R Meredith I Malaiapan Y Psaltis PJ An overview of PCI in the very elderly. J Geriatr Cardiol. 2015; 12: 174-184 PubMed Google Scholar However, these patients might be less eligible for revascularisation or at higher risk of procedural complications when they receive revascularisation therapy. These might be the reasons why patients aged 80 years or older are frequently under-represented in clinical revascularisation trials. The scarcity of evidence detailing the optimal choice of treatment in the different subsets of a heterogeneous older population might be an explanation of why older patients are less likely to receive an invasive strategy and are more often treated with a more conservative medical strategy. There is also considerable doubt among physicians about how to treat these patients, due to uncertainty about risk versus benefit in any treatment strategy. Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical dataThe survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older. Full-Text PDF Open Access