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Review

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Abdulla A Damluji et al. Circulation. .

Abstract

Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.

Keywords: AHA Scientific Statements; acute coronary syndrome; cardiovascular diseases; frailty; geriatric assessment; multimorbidity; polypharmacy.

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Figures

Figure 1.
Figure 1.
The bidirectional association between acute coronary syndrome and geriatric syndromes. Several factors influence this bidirectional association including phenotypic aging, physiologic mechanisms, cellular and subcellular mechanisms, genetics, and the environment.
Figure 2.
Figure 2.
A. Classification system for acute and chronic myocardial injury. B. The number of patients with each universal definition of myocardial infarction (UDMI). Modified with permission from Morrow et al.
Figure 3.
Figure 3.
A. Absorption, metabolism, distribution, and elimination of guideline directed medical therapy in older adults with acute coronary syndromes. B. Changes in small intestine and liver that influence drug metabolism in older adults with acute coronary syndrome.
Figure 4.
Figure 4.
Post discharge plan with shared decision making for older adults with acute coronary syndrome focusing on (1) medications, (2) lifestyle modification/cardiac rehabilitation, (3) management of comorbidities, (4) psychosocial support, (5) socioeconomic factors, and (6) patient/family education. Family and patient education is a collaborative effort performed by the primary medical team, and corroborated by cardiologist, geriatrician and social worker to improve overall comprehensive and health literacy.
See this image and copyright information in PMC

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