AHA issues scientific statement on ACS in older patients

A scientific statement from the American Heart Association provided updated recommendations for management of acute coronary syndrome (ACS) in older patients.

The scientific statement reviewed age-related physiological changes that can lead to acute coronary syndrome, described the effects of common geriatric syndromes on cardiovascular disease outcomes, and recommended age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies. The statement, which was published Dec. 12 by Circulation, offered “a synthesis of the information that has proliferated since the publication” of the organization's 2007 statement on the subject and particularly focused on patients ages 75 years and older.

The statement offered clinical considerations on each topic. Some relevant to hospital medicine include:

• ACS represents a small proportion of all chest pain presentations in younger and older adults. ACS presentations without chest pain, such as shortness of breath, syncope, or sudden confusion, are more likely to occur in older adults.
• High-sensitivity troponin assays are standard of care for identifying acute and chronic myocardial injury, but many older adults have persistent elevations attributable to myocardial fibrosis and chronic kidney disease that lessen the positive predictive value, so evaluating patterns of rise and fall is essential.
• In the older patient with ACS, clopidogrel is the preferred P2Y12 inhibitor because of a significantly lower bleeding profile than ticagrelor or prasugrel, but for patients with ST-elevation myocardial infarction (STEMI) or complex anatomy, the use of ticagrelor is reasonable.
• Older adults, particularly those with mobility or cognitive difficulties, may benefit from relatively simpler medication and dosing regimens than those commonly indicated by existing guidelines. Comorbidities, geriatric syndromes, and personal health care goals and preferences are also relevant factors to integrate within tailored regimens of care.
• Immediate myocardial reperfusion by primary percutaneous coronary intervention (PCI) is beneficial in older patients with STEMI and may also reduce recurrent MI and repeat revascularization in patients with NSTEMI, but for older patients with cardiogenic shock and cardiac arrest, careful consideration of the high risk of adverse outcomes or futility of PCI is warranted.
• Transitions of care are high-risk times for older adults after ACS; coordination of clinicians is integral to a successful discharge/transitional care plan for older patients with ACS. A detailed medication review and reconciliation are essential, ideally in collaboration with a pharmacist, to ensure that, once at home, the patient has access to and is taking the medications prescribed at discharge and that they are integrated with any additional pharmaceuticals acquired over-the-counter and from other clinicians.
• Cardiac rehabilitation (CR) targets functional enhancement as a key outcome benefit. For many older adults, this is a vital clinical priority that is not fostered by other aspects of treatment, thereby reinforcing the distinctive value of CR.
• Frailty is biologically linked to coronary artery disease and plays a key role in ACS management. CR provides opportunity for strength training, nutritional emphasis, and other strategies to mitigate frailty effects and improve patient-centered outcomes. Whereas many clinicians avoid CR for patients who are frail, in fact, patients who are frail often benefit the most.

“The management of ACS in the older adult population is more complex than in younger patients because of their anatomic complexity, physiological vulnerability, age-related risks (including prevalent geriatric syndromes), and heterogeneity in life expectancy and goals of care,” the statement concluded.