ACUTE CORONARY SYNDROME IN ELDERLY: CURRENT STATUS AND UNRESOLVED ISSUES

Cardiovascular diseases impact at most the morbidity, mortality and life quality of the elderly. However this population is underrepresented in clinical trials, hence  management of this sort of patients  is a gap  in evidence.  Acute coronary  syndrome  (ACS) requires  active treatment from the very first minutes from myocardial ischemia onset.  The riskbenefit ratio of invasive approach in a very old is still foggy, as there is no consideration of the risks related to frailty and other individual specifics of a patient, as the comorbidities.

In the article, randomized trials data is presented, as of registries, that included  aimfully ACS patients  75 years  and  older.  The specifics  of intervention is pointed in, its efficacy, and complications of reperfusion therapy in ACS with ST elevation (STEMI) in the senile.

In details, an issue considered  on the tactics of ACS treatment in nonST-elevation  ACS (NSTEMI), as  the  rationale  for  earlier  invasive tactics  — coronary  arteriography  and,  if  indicated,  percutaneous coronary intervention during 72 hours, or the conservative therapy at first, and coronary arteriography and revascularization only if ischemia recur; safety of the primary invasive approach;  interventional approach  by default or individualized approach  and influence of such choice on 5-year cardiovascular mortality and myocardial infarction. Special  attention  is  paid  on  a  necessity   of  geriatric  support  of patients, presence and significance of the frailty and its influence on ACS treatment   outcomes,   life quality of  the  old  after  ACS, and organization of ACS registry of ≥80 y. o. persons  from various regions of Russia.

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13. Damman P, Clayton T, Wallentin L, et al. Effects of age on long-term outcomes after a routine invasive or selective invasive strategy in patients presenting with non-ST segment elevation acute coronary syndromes: a collaborative analysis of individual data from the FRISC II ICTUS RITA-3 (FIR) trials. Heart 2012; 98: 207-13.

14. Roe MT, Goodman SG, Ohman EM, et al. Elderly patients with acute coronary syndromes managed without revascularization insights into the safety of long-term dual antiplatelet therapy with reduced-dose prasugrel versus standard-dose clopidogrel. Circulation 2013; 128: 823-33.

15. Centers for Disease Control and Prevention. MMWR series on public health and aging. MMWR Morb Mortal Wkly Rep 2003; 52: 101-6.

16. Nikolich-Žugich J, Goldman DP, Cohen PR, et al. Preparing for an Aging World: Engaging Biogerontologists, Geriatricians, and the Society. J Gerontol A Biol Sci Med Sci 2016; 71(4): 435-4.

17. Rich MW, Chyun DA, Skolnick AH, et al. American Heart Association Older Populations Committee of the Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council; American College of Cardiology; and American Geriatrics Society.

18. Knowledge gaps in cardiovascular care of the older adult population: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society. Circulation 2016; 133: 2103-22. doi: 10.1161/CIR.0000000000000380.

19. Olivari Z, Steffenino G, Savonitto S, et al. BLITZ 4 Investigators. The management of acute myocardial infarction in the cardiological intensive care units in Italy: the ‘BLITZ 4 Qualita’ campaign for performance measurement. Eur Heart J Acute Cardiovasc Care 2012; 1: 143-52.

20. Bach RG, Cannon CP, Weintraub WS, et al. The effect of routine, early invasive management on outcome for elderly patients with non–ST-segment elevation acute coronary syndromes. Ann Intern Med 2004; 141: 189-95.

21. Radovanovic D, Seifert B, Urban P, et al. AMIS Plus Investigators Validity of Charlson Comorbidity Index in patients hospitalised with acute coronary syndrome. Insights from the nationwide AMIS Plus registry 2002-2012. Heart 2014; 100(4): 288-94.

22. Amsterdam EA, Wenger NK, Brindis RG, et al. ACC/AHA Task Force Members. 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 Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130: e344-426.

23. Roe MT, Goodman SG, Ohman EM, et al. Elderly patients with acute coronary syndromes managed without revascularization insights into the safety of long-term dual antiplatelet therapy with reduced-dose prasugrel versus standard-dose clopidogrel. Circulation 2013; 128: 823-33.

24. Bueno H, Betriu A, Heras M, et al. TRIANA Investigators. Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J 2011; 32: 51-60.

25. Savonitto S, Cavallini C, Petronio AS, et al. Italian Elderly ACS Trial Investigators. Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial. JACC Cardiovasc Interventions 2012; 5: 906-16.

26. Damman P, Clayton T, Wallentin L, et al. Effects of age on long-term outcomes after a routine invasive or selective invasive strategy in patients presenting with non-ST segment elevation acute coronary syndromes: a collaborative analysis of individual data from the FRISC II ICTUS RITA-3 (FIR) trials. Heart 2012; 98: 207-13.

27. Roe MT, Goodman SG, Ohman EM, et al. Elderly patients with acute coronary syndromes managed without revascularization insights into the safety of long-term dual antiplatelet therapy with reduced-dose prasugrel versus standard-dose clopidogrel. Circulation 2013; 128: 823-33.