Older patients who experience an acute coronary syndrome (ACS) are more complex to treat than their younger counterparts because of the effects of aging and comorbidities. With that in mind, the American Heart Association (AHA) issued a scientific statement Monday that seeks to incorporate geriatric risks into a treatment framework. Abdulla A. Damluji, MD, PhD, of the Johns Hopkins University, Baltimore, and Inova Center of Outcomes Research, Fairfax, Virginia, chaired the group that wrote the statement, which was published Monday online in Circulation, and updates a two-part AHA statement published in 2007 concerning care of older adults with non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI). The statement notes that about 720,000 Americans die each year of acute myocardial infarction (MI) or coronary artery disease (CAD), and more than 335,000 Americans experience recurrent related events annually. Older adults, defined as those 75 years and older, comprise 30% to 40% of all hospitalized patients with ACS and make up a majority of ACS-related deaths. These patients often have heavy atherosclerotic plaque burden, complex anatomies, calcification, tortuous vessels, ostial lesions, multivessel disease and left main coronary artery stenosis. They are also more likely to have concomitant geriatric syndromes that further compound their aggregate prognostic risk, and a substantial portion are frail, have multiple morbidities, cognitive impairment, functional decline, nutritional deficiencies or polypharmacy, among other conditions. “Older patients have more pronounced anatomical changes and more severe functional impairment, and they are more likely to have additional health conditions not related to heart disease,” Damluji said in an AHA news release announcing the scientific statement. “These include frailty, other chronic disorders (treated with multiple medications), physical dysfunction, cognitive decline and/or urinary incontinence – and these are not regularly studied in the context of ACS.” Classifying ACS ACS causes only a small percentage of chest pain that both younger and older adults experience. Also, older adults are more likely to experience ACS without chest pain, but with other symptoms such as dyspnea, syncope or sudden confusion. The standard of care of identifying acute and chronic myocardial injury is high-sensitivity cardiac troponin assays, but older adults often have persistently high troponin levels caused by myocardial fibrosis or chronic kidney disease. Therefore, clinicians should evaluate the patterns of troponin level rise and fall, the statement says. The four types of myocardial injury – acute non-ischemic injury, chronic injury, and type 1 and 2 MI – are all more common in older than in younger adults, the statement says. Pharmacotherapy Clopidogrel is the “preferred” P2Y12 inhibitor in older patients with ACS because it has a significantly lower bleeding profile than ticagrelor or prasugrel, the statement says. However, for patients with STEMI or complex anatomy, the statement says that ticagrelor is a “reasonable” treatment. Patients with atrial fibrillation who undergo percutaneous coronary intervention (PCI) for ACS should have minimized triple therapy. Aspirin should be stopped and the patient transitioned to dual antithrombotic therapy with clopidogrel and a new oral anticoagulant, “ideally within 4 weeks of PCI,” according to the statement. Outpatient follow-up is the best way to evaluate therapies begun in the hospital, with escalation as needed to reduce cardiovascular risk or de-escalation to relieve or prevent side effects. Older adults with mobility or cognitive difficulties might benefit from simpler medication regimens than those typically recommended in existing guidelines. Other factors to consider include the patient’s comorbidities, geriatric syndromes, and personal healthcare goals and preferences. “Geriatric syndromes and the complexities of their care may undermine the effectiveness of treatments for ACS, as well as the resiliency of older adults to survive and recover,” Damluji said in the news release. “A detailed review of all medications – including supplements and over-the-counter medicines – is essential, ideally in consultation with a pharmacist who has geriatric expertise.” PCI in older adults Because there is not yet a more specific risk score for older adults with ACS, the statement recommends – per the American College of Cardiology/AHA chest pain and revascularization guidelines – that patients with suspected NSTEMI be evaluated using the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores, with additional emphasis on high-sensitivity troponins. While geriatric syndromes are relevant, they are not formally included in the risk assessment. Older patients with STEMI benefit from immediate myocardial reperfusion with primary PCI, which might also reduce recurrent MI and repeat revascularization in patients with NSTEMI. However, for patients with cardiogenic shock and cardiac arrest, the decision to use PCI as treatment should be carefully considered “given their high inherent risk for adverse outcomes and futility,” the statement says. Major bleeding risk can be lowered with the use of radial access; adjusting the dosing of anticoagulant and antithrombotic therapy based on the patient’s age, weight and kidney function; and using a shorter duration of dual antiplatelet therapy with clopidogrel, especially in older adults with high bleeding risk. The statement says that “ideally,” the multidisciplinary team caring for older patients with ACS would include cardiologists, surgeons, geriatricians, primary care clinicians, nutritionists, cardiac rehabilitation professionals, social workers, nurses, family members and pharmacists, “but centers should tailor their team according to available resources and patient needs.” Advanced do-not-resuscitate directives need to be carefully discussed with patients, family or their power of attorney before invasive management and primary PCI, and such advanced directives “should be suspended for the duration of the procedure,” according to the statement. Surgery Coronary artery bypass graft (CABG) has been associated with better survival and lower risk or repeat revascularization and MI in selected older adults with left main or multivessel disease. However, the statement recommends a Heart Team approach to the revascularization strategy, including professionals with geriatric expertise to assess frailty, multimorbidity, cognition “and other pertinent age-related elements of care.” While the Society of Thoracic Surgeons Predicted Risk of Mortality Outcome Measures score can calculate the risk of 30-day mortality after CABG at all ages, additional considerations that might reduce the safety and efficacy of surgical revascularization in older patients include severe cognitive impairment, frailty, cerebrovascular disease and aortic calcification. CABG with the goal of complete revascularization has shown survival benefit in older adults with left main or multivessel disease, but the statement says shared decision-making with the patient and family “is critical, particularly among very old adults.” The statement adds that percutaneous revascularization with medical therapy or medical therapy alone is also reasonable “if symptom control is a primary patient-centered goal.” The statement adds that tailoring operative techniques and perioperative management to include preoperative and intraoperative imaging of aortic and cerebrovascular disease, and aggressive prevention and treatment of atrial fibrillation, can minimize stroke risk. The statement also includes detailed descriptions of cardiovascular aging, geriatric syndromes, prevention of acute kidney injury in older patients undergoing revascularization, futility, transitions of care, cardiac rehabilitation and follow-up. Source: Damluji AA, Forman DE, Wang TY, et al.; on behalf of the American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology; Council on Lifestyle and Cardiometabolic Health; and Council on Cardiovascular Radiology and Intervention. Management of acute coronary syndrome in the older adult population: A scientific statement from the American Heart Association. Circulation 2022 Dec 12 (Article in press). Image Credit: PoppyPix – stock.adobe.com