Challenges in the management of older patients with acute coronary syndromes in the COVID-19 pandemic

Abstract

Ischaemic heart disease (IHD), in particular acute coronary syndrome (ACS), comprising ST-elevation myocardial infarction, non-ST-elevation myocardial infarction and unstable angina, is the leading cause of death worldwide. Age is a major predictor of adverse outcome following ACS. COVID-19 infection seems to escalate the risk in older patients with heart disease. Increasing odds of in-hospital death is associated with older age following COVID-19 infection. Importantly, it seems older patients with comorbidities such as cardiovascular disease (CVD), in particular IHD, diabetes and hypertension, are at the highest risk of mortality following COVID-19 infection. The evidence is sparse on the optimal care of older patients with ACS with lack of robust randomised controlled trials. In this setting, with the serious threat imposed by the COVID-19 pandemic in the context of rapidly evolving knowledge with much unknown, it is important to weigh the risks and benefits of treatment strategies offered to older patients. In cases where risks outweigh the benefits, it might not be an unreasonable option to treat such patients with a conservative or a palliative approach. Further evidence to elucidate whether invasive management is beneficial in older patients with ACS is required out-with the COVID-19 pandemic. Though it is hoped that the actual acute phase of COVID-19 infection will be short lived, it is vital that important clinical research is continued, given the long-term benefits of ongoing clinical research for patients with long-term conditions, including CVD. This review aimed to evaluate the challenges and the management strategies in the care of older patients presenting with ACS in the context of the COVID-19 pandemic.

Keywords: acute coronary syndromes; cardiac catheterisation and angiography; coronary artery disease.

Figure 1

Hypothesised pathogenesis of acute cardiac injury in older patients. AKI, acute kidney injury; ARDS, acute respiratory distress syndrome; CCL5, chemokine ligand 5; CK, creatine kinase; CXCL8, C-X-C motif chemokine ligand 8; GI, gastrointestinal; IFN-1, interferon type 1; LDH, lactate dehydrogenase; Na, sodium; RAAS; renin–angiotensin–aldosterone system; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; Th1, type 1 T-helper cell.

Figure 2

Individualised care of older patients. ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; Rx, treatment.