Management of Stable Angina in the Older Adult Population

Abstract

As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient's priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.

Keywords: aged; aging; angina, stable; coronary artery disease; morbidity; percutaneous coronary intervention.

Figure 1.. Contributors to the Heterogeneity of Chronological Aging.

Figure 1 highlights the array of markers and measures that contribute to the heterogeneity of “biological” aging across chronological age.

Figure 2.. Interpretation of Symptoms in Older Adults with Multimorbidity.

Figure 2 presents some of the multitude of symptoms that are potentially associated with stable ischemic heart disease in older adults and examples of the potential competing conditions that can contribute to the burden of that particular symptom.

Figure 3.. A Novel Framework for Approaching Treatment Decisions in Older Adults with Stable Angina.

Figure 3 presents a framework for approaching complex treatment decisions in older adults with stable angina within the context of competing conditions, individual patient priorities, preferences, and goals, as well as potential benefits, tradeoffs, and harms of the available treatments, which are listed in order of priority (lifestyle, medical, and invasive therapies).