Pharmacological treatment of elderly patients with acute coronary syndromes without persistent ST segment elevation

Abstract

Evidence-based management of acute coronary syndromes (ACS) without persistent ST segment elevation involves a rational, stepwise approach to the selection of therapies with potential benefit for elderly patients. Specifically, in elderly patients with ACS without persistent ST segment elevation, therapy should be administered based on the likelihood of unstable angina or non-ST elevation myocardial infarction being present and the risks and benefits of each individual therapy. All elderly patients with suspected ACS should receive anti-ischaemic therapy consisting of beta-blockers and nitrates, and antiplatelet therapy with aspirin unless clear contraindications exist. For patients with a moderate likelihood of ACS being present, defined as prior coronary disease or recurrent pain despite the use of anti-ischaemic therapies, unfractionated heparin or enoxaparin should be added to aspirin for more intense anticoagulation. In patients with high-risk clinical features, defined as ischaemic electrocardiographic changes and positive cardiac markers such as troponins, therapy with clopidogrel or glycoprotein IIb/IIIa inhibitors should be considered in addition to aspirin and heparin. Furthermore, high-risk patients should be managed with an early invasive strategy that includes prompt cardiac catheterisation within 24 to 48 hours and appropriate use of revascularisation as determined by the findings of the catheterisation. An evidence-based approach to the treatment of elderly patients with ACS without persistent ST segment elevation will help to improve the use of beneficial therapies and interventions that are recommended by current practice guidelines.