Management of Acute Coronary Syndrome in Elderly Patients: A Narrative Review through Decisional Crossroads

Abstract

Diagnosis and treatment of acute coronary syndrome (ACS) pose particular challenges in elderly patients. When high troponin levels are detected, the distinction between non-ischemic myocardial injury (NIMI), type 1, and type 2 myocardial infarction (MI) is the necessary first step to guide further care. However, the assessment of signs of ischemia is hindered in older patients, and no simple clinical or laboratory tool proved useful in this discrimination task. Current evidence suggests a benefit of an invasive vs. conservative approach in terms of recurrence of MI, with no significant impact on mortality. In patients with multivessel disease in which the culprit lesion has been treated, a physiology-guided complete percutaneous revascularization significantly reduced major events. The management of ACS in elderly patients is an example of the actual need for a multimodal, thorough clinical approach, coupled with shared decision-making, in order to ensure the best treatment and avoid futility. Such a need will likely grow throughout the next decades, with the aging of the world population. In this narrative review, we address pivotal yet common questions arising in clinical practice while caring for elderly patients with ACS.

Keywords: ACS; NSTEMI; acute myocardial infarction; elderly; myocardial injury; older; revascularization; type 2 myocardial infarction.

Figure 1

Predisposing and precipitating factors of type 2 myocardial infarction.

Figure 2

Diagnostic approach to elderly patients with suspected ACS. ACS = acute coronary syndrome; URL = upper reference limit; ECG = electrocardiogram; CMR = cardiac magnetic resonance; CCTA = coronary computed tomography angiography; MI = myocardial infarction; NIMI = non-ischemic myocardial injury; Hb = hemoglobin; BNP = brain natriuretic peptide; CRP = C reactive protein.