ACS Care in Older Patients Entails Unique Risks, Shifting Goals, Says AHA

Age-related physiological changes, a greater burden of cardiovascular risk factors, and higher rates of chronic health conditions are among the issues that need to be taken into consideration when managing ACS in patients 75 and older, according to an updated scientific statement from the American Heart Association (AHA).

Roughly 30% to 40% of all patients hospitalized with ACS fall in this older age group, in which most ACS-related deaths occur and outcomes are generally poorer when compared with the younger groups.

The problem when it comes to ACS management is that key randomized trials on which guideline recommendations are based have largely excluded older patients, who are more likely to have geriatric syndromes like frailty, multimorbidity, and poor cognitive and physical function, and to be taking several medications already, according to Abdulla Damluji, MD, PhD (Inova Center of Outcomes Research, Fairfax, VA, and Johns Hopkins School of Medicine, Baltimore, MD), who chaired the group behind the new AHA statement.

“All of these conditions are common in older adults and they influence our choices of therapy and they influence our cardiovascular outcomes,” Damluji told TCTMD.

As cardiologists, we don’t know how to assess age-associated risks because we’re not geriatricians. Abdulla Damluji

Published online this week in Circulation, the AHA statement—which updates a previous document on acute coronary care in elderly patients released in 2007—is intended to help navigate various tricky scenarios in this setting.

“As cardiologists, we don’t know how to assess age-associated risks because we’re not geriatricians,” Damluji said, noting that existing practice guidelines provide good overall recommendations but don’t necessarily address the nuances of treating older patients. “That’s where this statement comes in, to fill in this gap.”

A Unique Population

The authors review age-related physiological changes that both increase susceptibility to CVD and complicate ACS management; discuss the impact of various geriatric syndromes; and make recommendations regarding revascularization and other strategies that account for these variables, incorporating discussions of transitions of care, cardiac rehabilitation, palliative care, and holistic approaches. “The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout,” Damluji et al write.

Some key points:

• There are several age-related physiological changes to consider when managing ACS. These include increased central aortic stiffness, altered LV diastolic relaxation and increased myocardial stiffness, chronic low-grade inflammation, an altered balance between thrombosis and fibrinolysis that raises the risk for venous and arterial thromboembolism, and declining renal function that increases the risk of contrast-induced acute kidney injury.
• Geriatric syndromes like frailty, cognitive and physical impairments, delirium, and sensory problems become more common at older ages. They worsen ACS outcomes and, conversely, are exacerbated by acute coronary events.
• ACS is more likely to occur without accompanying chest pain in older age groups, with symptoms like shortness of breath, syncope, or sudden confusion being more common.
• Because cardiac troponin levels may already be elevated in older patients due to myocardial fibrosis or chronic kidney disease, it’s more important to assess how levels change over time when diagnosing MI.
• Based on studies like Elderly ACS 2, POPular AGE, and SWEDEHEART, clopidogrel should be the preferred P2Y12 inhibitor in older patients due to the lower risk of bleeding and similar efficacy compared with more-potent agents like ticagrelor and prasugrel.
• Simpler medication and dosing regimens may be useful, particularly for patients with mobility or cognitive difficulties.
• Cardiac rehabilitation, which may be especially beneficial in patients with frailty, “is best used with a tailored approach that addresses each patient’s distinctive circumstances and goals of care.”

Importantly, the statement authors say, physicians should not solely focus on clinical outcomes when treating patients. “When managing older patients presenting with ACS, the goals of care should extend beyond traditional cardiovascular outcomes to include patient-aligned goals and preferences that maximize quality-of-life outcomes,” they write.

In addition, they recommend pulling in clinicians from a variety of specialties to help manage older patients with ACS: “Ideally, the multidisciplinary team that cares for older patients with ACS includes cardiologists, surgeons, geriatricians, primary care clinicians, nutritionist, cardiac rehabilitation professionals, social workers, nurses, family members, and pharmacists, but centers should tailor their team according to available resources and patient needs.”

Complementary to Practice Guidelines

Damluji said this AHA statement adds to what’s found in practice guidelines by delving into the intricacies of treating older patients. The document goes over factors that drive decisions about percutaneous or surgical revascularization and also provides a discussion about futility, when an invasive approach is not warranted.

“For older patients at a high risk for death and adverse outcomes, a major challenge is to identify futility before rather than after revascularization, but establishing goals of care in older patients from the outset may help avoid unwanted or futile intervention,” the authors write.

The hope, Damluji said, is that this document, which covers the entire spectrum of ACS care from when a patient arrives at the hospital to when they transition to outpatient care after discharge, will spark further pragmatic clinical trials to address some of the areas of uncertainty in older patients. These results would “become more helpful to practice as we care for more complex patients in real life,” he said.

In addition, future iterations of practice guidelines for ACS and coronary revascularization will ideally integrate more of the information found in this statement to better reflect the unique considerations around managing older patients, he said.