The new statement, “Management of acute
coronary syndrome (ACS) in the older adult population,” highlights recent
evidence to help clinicians better care for patients over age 75. According to
the statement, 30-40% of people hospitalized with ACS are age 75 or older. ACS
includes heart attack and unstable angina (heart-related chest pain).
The statement is an update of a 2007 American
Heart Association statement on the treatment of heart attacks in the elderly.
For people ages 75 and older, age-related changes
in general health and in the heart and blood vessels require consideration and
likely modifications in how heart attacks and heart disease are treated. The
statement was published in the Association’s flagship, peer-reviewed journal
Circulation.
Clinical practice guidelines are based on
clinical trial research. “However, older adults are often excluded from
clinical trials because their health care needs are more complex when compared
to younger patients,” said Abdulla A. Damluji, M.D., Ph.D., FAHA, chair of the
scientific statement writing committee, director of the Inova Center of
Outcomes Research in Fairfax, Virginia, and an associate professor of medicine
at Johns Hopkins School of Medicine in Baltimore.
“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,” said Damluji.
“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.”
Normal aging and age-related changes in the
heart and blood vessels
Cardiovascular changes that occur with normal
aging make ACS more likely and may make diagnosing and treating it more
complex: large arteries become stiffer; the heart muscle often works harder but
pumps less effectively; blood vessels are less flexible and less able to
respond to changes in the heart’s oxygen needs; and there is an increased
tendency to form blood clots. Sensory decline due to aging may also alter
hearing, vision and pain sensations. Kidney function also declines with age,
with more than one-third of people ages 65 and older having chronic kidney
disease. These changes should be considered when diagnosing and treating ACS in
older adults.
These considerations include:
● ACS is more
likely to occur without chest pain in older adults, presenting with symptoms
such as shortness of breath, fainting or sudden confusion.
● Measuring
levels of the enzyme troponin in the blood is a standard test to diagnose a
heart attack in younger people. However, troponin levels may already be higher
in older people, especially those with kidney disease and a stiffened heart
muscle. Evaluating patterns of the rise and fall of troponin levels may be more
appropriate when using it to diagnose heart attacks in older adults.
● Age-related
changes in metabolism, weight and muscle mass may necessitate different choices
in anti-clotting medications to lower bleeding risk.
● As kidney
function declines, the risk of kidney injury increases, particularly when
contrast agents are used in imaging tests and procedures guided by imaging.
● Although many
clinicians avoid cardiac rehabilitation for patients who are frail, they often
benefit the most.
●
Ensuring medications and other therapies are
continued when people are transferred from the hospital to an outpatient care
center is particularly important in older adults who are vulnerable to frailty,
decline and complications during these transitions.
Multiple medical conditions and medications
As people age, they are often diagnosed with
health conditions that may be worsened by ACS or may complicate existing ACS.
As these chronic conditions are treated, the number of medications prescribed
may result in unwanted interactions or medications that treat one condition may
worsen another.
“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,” said Damluji. “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.”
An individualized and patient-centered approach
to ACS care, considering coexisting conditions and the need for input from
multiple specialists, is best for older adults. Ideally, the multidisciplinary
teams caring for older adults with ACS include cardiologists, surgeons,
geriatricians, primary care clinicians, nutritionists, pharmacists, cardiac
rehabilitation professionals, social workers, nurses and family members.
In addition, people with cognitive difficulties
and limited mobility may benefit from a simplified medication schedule, with
fewer doses per day and 90-day supplies of medications so fewer refills are
necessary. Monitoring symptom burden, functional status and quality of life
during post-discharge follow-up are important to provide insight into how the
patient is progressing relative to their goals of care and gauging potential
for improvement.
Patient preferences and life expectancy
Older adults differ widely in their
independence, physical or cognitive limitations, life expectancy and goals for
the future. The goals of care for older people with ACS should extend beyond
clinical outcomes (such as bleeding, stroke, another heart attack or the need
for repeat procedures to reopen arteries). Goals focused on quality of life,
the ability to live independently and/or returning to their previous lifestyle
or living environment are important to consider when planning care for older
adults with ACS. In addition, do-not-resuscitate (DNR) orders should be
discussed before any surgery or procedure.
● Although the
risks are greater, bypass surgery or procedures to reopen a clogged artery are
beneficial to select older adults with ACS.
● If invasive
treatment is chosen, a DNR order may need to be suspended for the duration of
the procedure.
● If invasive
treatment is not chosen, palliative care may help to manage symptoms, improve
quality of life and provide psychosocial support.
●
Important metrics for quality care include
measurable goals, such as days spent at home and relief of pain and discomfort.
Reference:
Abdulla A. Damluji et al, Management of Acute
Coronary Syndrome in the Older Adult Population: A Scientific Statement From
the American Heart Association, Circulation DOI 10.1161/CIR.0000000000001112