Skip to main content

Advertisement

SpringerLink
Log in

Challenges and Controversies in the Management of ACS in Elderly Patients

  • Management of Acute Coronary Syndromes (H Jneid, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Elderly patients presenting with acute coronary syndrome (ACS) represent a challenging patient population. A high index of suspicion is needed for their diagnosis, as they are less likely to present with typical anginal symptoms compared to their younger counterparts.

Recent Findings

Disrupted coronary plaques with superimposed thrombosis are the predominant pathophysiology of ACS; however, an increased proportion of calcified nodules is encountered in elderly patients. Emergent reperfusion and revascularization remain the mainstay treatment for ST-elevation myocardial infarction or cardiogenic shock. In elderly patients with NSTE-ACS, a routine invasive strategy is generally superior to an ischemia-guided strategy, and the safety of an early invasive strategy has also been recently demonstrated.

Summary

When treating elderly ACS patients with antiplatelet and antithrombotic therapies, close attention to co-morbidities, frailty and the balance of ischemia-bleeding risk should be undertaken, and medication doses should be carefully adjusted. Overall, elderly patients with ACS remain undertreated with evidence-based therapies, experience worse outcomes, and represent an opportunity for enhancing and mitigating healthcare disparities.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, 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(3):267–315.

    CAS  PubMed  Google Scholar 

  2. Virmani R, Burke AP, Farb A, Kolodgie FD. Pathology of the vulnerable plaque. J Am Coll Cardiol. 2006;47(8 Suppl):C13–8.

    CAS  PubMed  Google Scholar 

  3. Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons from sudden coronary death: a comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol. 2000;20(5):1262–75.

    CAS  PubMed  Google Scholar 

  4. Jia H, Abtahian F, Aguirre AD, Lee S, Chia S, Lowe H, et al. In vivo diagnosis of plaque erosion and calcified nodule in patients with acute coronary syndrome by intravascular optical coherence tomography. J Am Coll Cardiol. 2013;62(19):1748–58.

    PubMed  Google Scholar 

  5. Lee T, Mintz GS, Matsumura M, Zhang W, Cao Y, Usui E, et al. Prevalence, predictors, and clinical presentation of a calcified nodule as assessed by optical coherence tomography. JACC Cardiovasc Imaging. 2017;10(8):883–91.

    PubMed  Google Scholar 

  6. Kobayashi N, Takano M, Tsurumi M, Shibata Y, Nishigoori S, Uchiyama S, et al. Features and outcomes of patients with calcified nodules at culprit lesions of acute coronary syndrome: an optical coherence tomography study. Cardiology. 2018;139(2):90–100.

    PubMed  Google Scholar 

  7. Grosmaitre P, Le Vavasseur O, Yachouh E, Courtial Y, Jacob X, Meyran S, et al. Significance of atypical symptoms for the diagnosis and management of myocardial infarction in elderly patients admitted to emergency departments. Arch Cardiovasc Dis. 2013;106(11):586–92.

    PubMed  Google Scholar 

  8. Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004;126(2):461–9.

    PubMed  Google Scholar 

  9. Kannel WB, Abbott RD. Incidence and prognosis of unrecognized myocardial infarction. An update on the Framingham study. N Engl J Med. 1984;311(18):1144–7.

    CAS  PubMed  Google Scholar 

  10. Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006;333(7578):1091.

    PubMed  PubMed Central  Google Scholar 

  11. Rathore SS, Weinfurt KP, Foody JM, Krumholz HM. Performance of the thrombolysis in myocardial infarction (TIMI) ST-elevation myocardial infarction risk score in a national cohort of elderly patients. Am Heart J. 2005;150(3):402–10.

    PubMed  PubMed Central  Google Scholar 

  12. Ariza-Sole A, Formiga F, Lorente V, Sanchez-Salado JC, Sanchez-Elvira G, Roura G, et al. Efficacy of bleeding risk scores in elderly patients with acute coronary syndromes. Rev Esp Cardiol (Engl Ed). 2014;67(6):463–70.

    PubMed  Google Scholar 

  13. O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362–425.

    PubMed  Google Scholar 

  14. Johansson B, Westermark P. Senile systemic amyloidosis: a clinico-pathological study of twelve patients with massive amyloid infiltration. Int J Cardiol. 1991;32(1):83–92.

    CAS  PubMed  Google Scholar 

  15. Sugiura M, Hiraoka K, Ohkawa S, Shimada H. A clinicopathological study on the heart diseases in the aged. The Morphological Classification of the 1, 000 Consecutive Autopsy Cases. Jpn Heart J. 1975;16(5):526–37.

    CAS  PubMed  Google Scholar 

  16. Smith RF, Jackson DH, Harthorne JW, Sanders CA. Acquired bundle branch block in a healthy population. Am Heart J. 1970;80(6):746–51.

    CAS  PubMed  Google Scholar 

  17. Jain S, Ting HT, Bell M, Bjerke CM, Lennon RJ, Gersh BJ, et al. Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. Am J Cardiol. 2011;107(8):1111–6.

    PubMed  Google Scholar 

  18. Stenestrand U, Tabrizi F, Lindback J, Englund A, Rosenqvist M, Wallentin L. Comorbidity and myocardial dysfunction are the main explanations for the higher 1-year mortality in acute myocardial infarction with left bundle-branch block. Circulation. 2004;110(14):1896–902.

    PubMed  Google Scholar 

  19. Stephenson K, Skali H, McMurray JJ, Velazquez EJ, Aylward PG, Kober L, et al. Long-term outcomes of left bundle branch block in high-risk survivors of acute myocardial infarction: the VALIANT experience. Heart Rhythm. 2007;4(3):308–13.

    PubMed  Google Scholar 

  20. Barron HV, Bowlby LJ, Breen T, Rogers WJ, Canto JG, Zhang Y, et al. Use of reperfusion therapy for acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2. Circulation. 1998;97(12):1150–6.

    CAS  PubMed  Google Scholar 

  21. Shlipak MG, Lyons WL, Go AS, Chou TM, Evans GT, Browner WS. Should the electrocardiogram be used to guide therapy for patients with left bundle-branch block and suspected myocardial infarction? JAMA. 1999;281(8):714–9.

    CAS  PubMed  Google Scholar 

  22. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). Circulation. 2018;138(20):e618–e51.

    PubMed  Google Scholar 

  23. Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. Circulation. 2014;130(25):e344–426.

    Google Scholar 

  24. Hughes S, Szeki I, Nash MJ, Thachil J. Anticoagulation in chronic kidney disease patients—the practical aspects. Clin Kidney J. 2014;7(5):442–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Al-Shaer MH, Ibrahim T. Safety and efficacy of fondaparinux in renal impairment. J Pharm Technol. 2015;31(4):161–6.

    CAS  PubMed Central  Google Scholar 

  26. Andreotti F, Rocca B, Husted S, Ajjan RA, ten Berg J, Cattaneo M, et al. Antithrombotic therapy in the elderly: expert position paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J. 2015;36(46):3238–49.

    CAS  PubMed  Google Scholar 

  27. Toleva O, Ibrahim Q, Brass N, Sookram S, Welsh R. Treatment choices in elderly patients with ST: elevation myocardial infarction—insights from the Vital Heart Response registry. Open Heart. 2015;2(1):e000235.

    PubMed  PubMed Central  Google Scholar 

  28. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124(23):e574–651.

    PubMed  Google Scholar 

  29. Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001–15.

    CAS  PubMed  Google Scholar 

  30. Alexopoulos D, Xanthopoulou I, Deftereos S, Sitafidis G, Kanakakis I, Hamilos M, et al. Contraindications/special warnings and precautions for use of contemporary oral antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention. – Insights From the GReek AntiPlatelet rEgistry (GRAPE) &ndash. Circ J. 2014;78(1):180–7.

    CAS  PubMed  Google Scholar 

  31. Rosove MH. Platelet glycoprotein IIb/IIIa inhibitors. Best Pract Res Clin Haematol. 2004;17(1):65–76.

    PubMed  Google Scholar 

  32. Savonitto S, Investigators ftGV, Armstrong PW, Investigators ftGV, Lincoff AM, Investigators ftGV, et al. Risk of intracranial haemorrhage with combined fibrinolytic and glycoprotein IIb/IIIa inhibitor therapy in acute myocardial infarction: dichotomous response as a function of age in the GUSTO V trial. Eur Heart J. 2003;24(20):1807–14.

    CAS  PubMed  Google Scholar 

  33. Armaganijan LV, Alexander KP, Huang Z, Tricoci P, Held C, Van de Werf F, et al. Effect of age on efficacy and safety of vorapaxar in patients with non-ST-segment elevation acute coronary syndrome: insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial. Am Heart J. 2016;178:176–84.

    CAS  PubMed  Google Scholar 

  34. Mischie AN, Andrei CL, Sinescu C, Bajraktari G, Ivan E, Chatziathanasiou GN, et al. Antithrombotic treatment tailoring and risk score evaluation in elderly patients diagnosed with an acute coronary syndrome. J Geriatr Cardiol. 2017;14(7):442–56.

    CAS  PubMed  PubMed Central  Google Scholar 

  35. Schiariti M, Saladini A, Missiroli B, Papalia F, Cuturello D, Puddu PE, et al. Safety of downstream high-dose tirofiban bolus among 1578 patients undergoing percutaneous coronary intervention: the Sant'ANna TIrofiban Safety study. J Cardiovasc Med (Hagerstown). 2010;11(4):250–9.

    Google Scholar 

  36. Sabatine MS, Cannon CP, Gibson CM, Lopez-Sendon JL, Montalescot G, Theroux P, et al. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. JAMA. 2005;294(10):1224–32.

    CAS  PubMed  Google Scholar 

  37. Ferri LA, Morici N, Grosseto D, Tortorella G, Bossi I, Sganzerla P, et al. A comparison of reduced-dose prasugrel and standard-dose clopidogrel in elderly patients with acute coronary syndromes undergoing early percutaneous revascularization: design and rationale of the randomized Elderly-ACS 2 study. Am Heart J. 2016;181:101–6.

    CAS  PubMed  Google Scholar 

  38. Savonitto S, Ferri LA, Piatti L, Grosseto D, Piovaccari G, Morici N, et al. Comparison of reduced-dose prasugrel and standard-dose clopidogrel in elderly patients with acute coronary syndromes undergoing early percutaneous revascularization. Circulation. 2018;137(23):2435–45.

    CAS  PubMed  Google Scholar 

  39. Alexander KP, Chen AY, Roe MT, Newby LK, Gibson CM, Allen-LaPointe NM, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA. 2005;294(24):3108–16.

    CAS  PubMed  Google Scholar 

  40. Alexander KP, Roe MT, Chen AY, Lytle BL, Pollack CV Jr, Foody JM, et al. Evolution in cardiovascular care for elderly patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative. J Am Coll Cardiol. 2005;46(8):1479–87.

    PubMed  Google Scholar 

  41. Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Kardiol Pol. 2017;75(12):1217–99.

    PubMed  Google Scholar 

  42. Costa F, van Klaveren D, James S, Heg D, Raber L, Feres F, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet. 2017;389(10073):1025–34.

    PubMed  Google Scholar 

  43. Yeh RW, Secemsky EA, Kereiakes DJ, Normand SL, Gershlick AH, Cohen DJ, et al. Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention. JAMA. 2016;315(16):1735–49.

    CAS  PubMed  PubMed Central  Google Scholar 

  44. Navarese EP, Schulze V, Andreotti F, Kowalewski M, Kolodziejczak M, Kandzari DE, et al. Comprehensive meta-analysis of safety and efficacy of bivalirudin versus heparin with or without routine glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndrome. JACC Cardiovasc Interv. 2015;8(1 Pt B):201–13.

    PubMed  Google Scholar 

  45. Steg PG, van’t Hof A, Hamm CW, Clemmensen P, Lapostolle F, Coste P, et al. Bivalirudin started during emergency transport for primary PCI. N Engl J Med. 2013;369(23):2207–17.

    CAS  PubMed  Google Scholar 

  46. Stone GW, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, Dudek D, et al. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008;358(21):2218–30.

    CAS  PubMed  Google Scholar 

  47. Dewilde WJ, Oirbans T, Verheugt FW, Kelder JC, De Smet BJ, Herrman JP, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013;381(9872):1107–15.

    CAS  PubMed  Google Scholar 

  48. Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, Wildgoose P, et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med. 2016;375(25):2423–34.

    CAS  Google Scholar 

  49. Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T, et al. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med. 2017;377(16):1513–24.

    CAS  PubMed  Google Scholar 

  50. Lopes RD, Heizer G, Aronson R, Vora AN, Massaro T, Mehran R, et al. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med. 2019;380(16):1509–24.

    CAS  Google Scholar 

  51. Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB, et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation. 2010;122(24):2619–33.

    PubMed  Google Scholar 

  52. Krumholz HM, Radford MJ, Wang Y, Chen J, Marciniak TA. Early beta-blocker therapy for acute myocardial infarction in elderly patients. Ann Intern Med. 1999;131(9):648–54.

    CAS  PubMed  Google Scholar 

  53. Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA. National use and effectiveness of beta-blockers for the treatment of elderly patients after acute myocardial infarction: National Cooperative Cardiovascular Project. JAMA. 1998;280(7):623–9.

    CAS  PubMed  Google Scholar 

  54. Chen ZM, Pan HC, Chen YP, Peto R, Collins R, Jiang LX, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366(9497):1622–32.

    CAS  PubMed  Google Scholar 

  55. Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA. 1997;277(2):115–21.

    CAS  PubMed  Google Scholar 

  56. Stone NJ. Statins in secondary prevention. Intensity Matters. 2017;69(22):2707–9.

    Google Scholar 

  57. Shepherd J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM, Cobbe SM, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet. 2002;360(9346):1623–30.

    CAS  PubMed  Google Scholar 

  58. Collins R, Armitage J, Parish S, Sleigh P, Peto R. Heart protection study collaborative G. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet. 2003;361(9374):2005–16.

    PubMed  Google Scholar 

  59. Pfeffer MA, Braunwald E, Moye LA, Basta L, Brown EJ Jr, Cuddy TE, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med. 1992;327(10):669–77.

    CAS  PubMed  Google Scholar 

  60. Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Lancet. 1993;342(8875):821–828.

  61. Krumholz HM, Chen YT, Wang Y, Radford MJ. Aspirin and angiotensin-converting enzyme inhibitors among elderly survivors of hospitalization for an acute myocardial infarction. Arch Intern Med. 2001;161(4):538–44.

    CAS  PubMed  Google Scholar 

  62. Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Kober L, Maggioni AP, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med. 2003;349(20):1893–906.

    CAS  PubMed  Google Scholar 

  63. Dickstein K, Kjekshus J. Group OSCotOS. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan. Lancet. 2002;360(9335):752–60.

    CAS  PubMed  Google Scholar 

  64. Pitt B, Bakris G, Ruilope LM, DiCarlo L, Mukherjee R, Investigators E. Serum potassium and clinical outcomes in the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS). Circulation. 2008;118(16):1643–50.

    CAS  PubMed  Google Scholar 

  65. Mehta RH, Rathore SS, Radford MJ, Wang Y, Wang Y, Krumholz HM. Acute myocardial infarction in the elderly: differences by age. J Am Coll Cardiol. 2001;38(3):736–41.

    CAS  PubMed  Google Scholar 

  66. Goldenberg I, Matetzky S, Halkin A, Roth A, Di Segni E, Freimark D, et al. Primary angioplasty with routine stenting compared with thrombolytic therapy in elderly patients with acute myocardial infarction. Am Heart J. 2003;145(5):862–7.

    PubMed  Google Scholar 

  67. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes Angioplasty Substudy I. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. N Engl J Med. 1997;336(23):1621–8.

  68. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13–20.

    PubMed  Google Scholar 

  69. Cannon CP, Gibson CM, McCabe CH, Adgey AA, Schweiger MJ, Sequeira RF, et al. TNK-tissue plasminogen activator compared with front-loaded alteplase in acute myocardial infarction: results of the TIMI 10B trial. Thrombolysis in Myocardial Infarction (TIMI) 10B Investigators. Circulation. 1998;98(25):2805–14.

    CAS  PubMed  Google Scholar 

  70. Investigators G. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993;329(10):673–82.

    Google Scholar 

  71. Assessment of the S, Efficacy of a New Thrombolytic Regimen I. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction. Lancet. 2001;358(9282):605–13.

    Google Scholar 

  72. de Boer MJ, Ottervanger JP. van 't Hof AW, Hoorntje JC, Suryapranata H, Zijlstra F, et al. Reperfusion therapy in elderly patients with acute myocardial infarction: a randomized comparison of primary angioplasty and thrombolytic therapy. J Am Coll Cardiol. 2002;39(11):1723–8.

    PubMed  Google Scholar 

  73. Bueno H, Betriu A, Heras M, Alonso JJ, Cequier A, Garcia EJ, et al. 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(1):51–60.

    PubMed  Google Scholar 

  74. Zeymer U, Hochadel M, Karcher AK, Thiele H, Darius H, Behrens S, et al. Procedural success rates and mortality in elderly patients with percutaneous coronary intervention for cardiogenic shock. JACC Cardiovasc Interv. 2019;12(18):1853–9.

    PubMed  Google Scholar 

  75. Dzavik V, Sleeper LA, Cocke TP, Moscucci M, Saucedo J, Hosat S, et al. Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry. Eur Heart J. 2003;24(9):828–37.

    CAS  PubMed  Google Scholar 

  76. Rogers PA, Daye J, Huang H, Blaustein A, Virani S, Alam M, et al. Revascularization improves mortality in elderly patients with acute myocardial infarction complicated by cardiogenic shock. Int J Cardiol. 2014;172(1):239–41.

    PubMed  Google Scholar 

  77. Damluji AA, Bandeen-Roche K, Berkower C, Boyd CM, Al-Damluji MS, Cohen MG, et al. Percutaneous coronary intervention in older patients with ST-segment elevation myocardial infarction and cardiogenic shock. J Am Coll Cardiol. 2019;73(15):1890–900.

    PubMed  PubMed Central  Google Scholar 

  78. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, et al. Acute coronary care in the elderly, part I: non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115(19):2549–69.

    PubMed  Google Scholar 

  79. Assessment of the S, Efficacy of a New Thrombolytic I, Van De Werf F, Adgey J, Ardissino D, Armstrong PW, et al. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial. Lancet. 1999;354(9180):716–22.

    Google Scholar 

  80. Van de Werf F, Barron HV, Armstrong PW, Granger CB, Berioli S, Barbash G, et al. Incidence and predictors of bleeding events after fibrinolytic therapy with fibrin-specific agents: a comparison of TNK-tPA and rt-PA. Eur Heart J. 2001;22(24):2253–61.

    PubMed  Google Scholar 

  81. Tegn N, Abdelnoor M, Aaberge L, Endresen K, Smith P, Aakhus S, et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial. Lancet. 2016;387(10023):1057–65.

  82. Savonitto S, Cavallini C, Petronio AS, Murena E, Antonicelli R, Sacco A, et al. Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial. JACC Cardiovasc Interv. 2012;5(9):906–16.

    PubMed  Google Scholar 

  83. Sanchis J, Nunez E, Barrabes JA, Marin F, Consuegra-Sanchez L, Ventura S, et al. Randomized comparison between the invasive and conservative strategies in comorbid elderly patients with non-ST elevation myocardial infarction. Eur J Intern Med. 2016;35:89–94.

    PubMed  Google Scholar 

  84. Damman P, Clayton T, Wallentin L, Lagerqvist B, Fox KA, Hirsch A, 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(3):207–13.

    PubMed  Google Scholar 

  85. Buber J, Goldenberg I, Kimron L, Guetta V. One-year outcome following coronary angiography in elderly patients with non-ST elevation myocardial infarction: real-world data from the Acute Coronary Syndromes Israeli Survey (ACSIS). Coron Artery Dis. 2013;24(2):102–9.

    PubMed  Google Scholar 

  86. Devlin G, Gore JM, Elliott J, Wijesinghe N, Eagle KA, Avezum A, et al. Management and 6-month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: The Global Registry of Acute Coronary Events. Eur Heart J. 2008;29(10):1275–82.

    PubMed  Google Scholar 

  87. Sanchis J, Nunez J, Bodi V, Nunez E, Garcia-Alvarez A, Bonanad C, et al. Influence of comorbid conditions on one-year outcomes in non-ST-segment elevation acute coronary syndrome. Mayo Clin Proc. 2011;86(4):291–6.

    PubMed  PubMed Central  Google Scholar 

  88. Bagnall AJ, Goodman SG, Fox KA, Yan RT, Gore JM, Cheema AN, et al. Influence of age on use of cardiac catheterization and associated outcomes in patients with non-ST-elevation acute coronary syndromes. Am J Cardiol. 2009;103(11):1530–6.

    PubMed  Google Scholar 

  89. Cantor WJ, Mehta SR, Yuan F, Dzavik V, Worthley M, Niemela K, et al. Radial versus femoral access for elderly patients with acute coronary syndrome undergoing coronary angiography and intervention: insights from the RIVAL trial. Am Heart J. 2015;170(5):880–6.

    PubMed  Google Scholar 

  90. Garg A, Garg L, Agarwal M, Rout A, Raheja H, Agrawal S, et al. Routine invasive versus selective invasive strategy in elderly patients older than 75 years with non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis. Mayo Clin Proc. 2018;93(4):436–44.

  91. Singh M, Rihal CS, Lennon RJ, Spertus JA, Nair KS, Roger VL. Influence of frailty and health status on outcomes in patients with coronary disease undergoing percutaneous revascularization. Circ: Cardiovasc Qual Outcomes. 2011;4(5):496–502.

    Google Scholar 

  92. Aamir S, Mohammed S, Sudhir R. Transradial approach for coronary procedures in the elderly population. J Geriatr Cardiol. 2016;13(9):798–806.

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Author notes

  1. Waleed T. Kayani and Mahin R. Khan contributed equally to this work.

Authors and Affiliations

  1. Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA

    Waleed T. Kayani & Hani Jneid

  2. Division of Cardiology, McLaren-Flint/Michigan State University, Flint, MI, USA

    Mahin R. Khan

  3. Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Matthew R. Deshotels

  4. Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA

    Hani Jneid

Authors
  1. Waleed T. Kayani
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mahin R. Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Matthew R. Deshotels
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hani Jneid
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Waleed T. Kayani.

Ethics declarations

Conflict of Interest

Waleed T. Kayani, Mahin R. Khan, Matthew R. Deshotels, and Hani Jneid declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Management of Acute Coronary Syndromes

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kayani, W.T., Khan, M.R., Deshotels, M.R. et al. Challenges and Controversies in the Management of ACS in Elderly Patients. Curr Cardiol Rep 22, 51 (2020). https://doi.org/10.1007/s11886-020-01298-x

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11886-020-01298-x

Keywords

Search

Navigation