Acute coronary syndrome (ACS) in older adults poses a heightened risk in older individuals due to physiological changes associated with aging. In older adults, increased atherosclerotic plaque, combined with the complexity of anatomical disease and age-related cardiovascular and non-cardiovascular comorbidities, contribute to a worse prognosis. Geriatric considerations in acute coronary syndrome such as frailty, multimorbidity, cognitive and physical impairment, polypharmacy, and other complexities of care for these patients can undermine the therapeutic efficacy of guideline-based treatments and the survival and recovery capacity of older adults.
That is why the American Heart Association (AHA) issued the document titled “Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association.” This document provides key recommendations for the management of acute coronary syndrome in older adults. It emphasizes the need for individualized risk assessment and the importance of considering patient preferences in treatment decisions. In this blog, we summarize some of the most relevant aspects of the AHA recommendations for clinical practice in this syndrome.
By América Torres
Cardiovascular Aging and Its Impact on Acute Coronary Syndrome in Older Adults
Clinical Considerations for Cardiovascular Aging in ACS
Understanding the pathophysiological changes derived from the process of cardiovascular aging and the aging kidney is crucial for evaluating guideline-based medical treatment for acute coronary syndrome in older adults. It is also important for managing age-related risks in order to prevent physical, cognitive, or functional decline in older individuals.
Role of Geriatric Syndromes in Acute Coronary Syndrome Outcomes
Patient-Centered Clinical Management of ACS in Elderly Patients
Geriatric syndromes can influence outcomes in older patients with acute coronary syndrome (ACS). Conversely, ACS can also worsen the burden of preexisting geriatric syndromes. Therefore, clinicians should adopt a comprehensive approach proportional to the relatively more complex issues related to ACS in older adults. They should also individualize and focus on patient-centered strategies that address overlapping and coexisting areas of healthcare.
Diagnostic Classification Based on Acute Coronary Syndrome in Older Adults
Key Diagnostic Considerations in Elderly Patients with ACS
- Symptoms of acute coronary syndrome in older adults often occur without chest pain. These symptoms may include shortness of breath, syncope, or sudden confusion.
- High-sensitivity troponin (hs-cTn) testing is the standard for identifying acute and chronic myocardial injury.
- Clinicians classify myocardial injury into four subtypes:
1. Acute non-ischemic injury
2. Chronic myocardial injury
3. Myocardial infarction (type 1)
4. Myocardial infarction (type 2).
All of these are more common in older adults than in younger adults.
Pharmacological Therapy Based on Guidelines for ACS in Older Adults
Guideline-Based Pharmacotherapy and Polypharmacy Considerations
• The preferred antiplatelet therapy for older adults with acute coronary syndrome (ACS) is clopidogrel. For patients with STEMI or complex anatomy, clinicians more reasonably use ticagrelor.
• In patients with chronic atrial fibrillation undergoing percutaneous coronary intervention (PCI) for ACS, clinicians should minimize the duration of triple therapy. The AHA Guidelines for the Management of Acute Coronary Syndrome in the Older Adults advise clinicians to discontinue aspirin. And also transition patients to dual antithrombotic therapy with clopidogrel and a novel oral anticoagulant, ideally within four weeks after PCI.
• Clinicians should evaluate therapies initiated in the hospital during outpatient follow-up and escalate treatment as needed to reduce cardiovascular risk. They should also reduce or withdraw medications when necessary to alleviate or prevent side effects.
• Older adults, especially those with mobility or cognitive difficulties, may benefit from simpler medication regimens. They may also require dosing strategies that differ from those commonly indicated by existing guidelines.
The following image illustrates the physiological changes that affect the pharmacokinetics and pharmacodynamics of medications used in older adults with acute coronary syndrome.
Percutaneous Revascularization Strategies in Older Adults with ACS
The management of STEMI in older adults follows the same general principles as for younger patients. However, in NSTEMI, revascularization strategies in elderly ACS patients require careful cardiovascular and non-cardiovascular risk assessment to optimize outcomes.
Geriatric and Patient-Centered Outcomes for Older Populations with Acute Coronary Syndrome
In patients with ACS, particularly in older populations, the goals of care should encompass patient-aligned objectives and preferences to maximize their quality of life. In addition, for patients approaching the end of life, treatment objectives include “days spent at home in the last 6 months of life” and relief of pain and discomfort.
Optimizing the Management of Acute Coronary Syndrome in Older Adults
The management of acute coronary syndrome (ACS) in older adults is more delicate due to their anatomical complexity, physiological vulnerability, age-related risks, and heterogeneity in life expectancy and care goals. In this scientific statement, the AHA proposes a framework for integrating geriatric risks into the management of ACS. This includes a diagnostic approach, pharmacotherapy, revascularization strategies, prevention of adverse events, and transition care planning. Additionally, it emphasizes that post-myocardial infarction care should include individualized cardiac rehabilitation.
Supporting Guideline-Based Diagnosis in Acute Coronary Syndrome
In this evolving clinical context, having reliable diagnostic tools is essential to support the approach outlined in the AHA scientific statement “Management of Acute Coronary Syndrome in the Older Adult Population.” SCHILLER’s cardiac solutions empower clinicians to obtain accurate and timely diagnostic information.Our electrocardiographs combine high sampling rates with advanced interpretation algorithms. Together, these capabilities support confident, efficient clinical decision-making in demanding care environments.
Therefore, we invite you to request a demonstration. In doing so, you can experience how SCHILLER’s technologies enhance diagnostic confidence and efficiency in the management of acute coronary syndrome in older adults.
REFERENCE
Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL 2nd, DeVon HA, Alexander KP; on behalf of the American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology; Council on Lifestyle and Cardiometabolic Health; and Council on Cardiovascular Radiology and Intervention. Management of acute coronary syndrome in the older adult population: a scientific statement from the American Heart Association. Circulation. 2023;147: e32–e62. doi:10.1161/CIR.0000000000001112
Frequently Asked Questions About Acute Coronary Syndrome in Older Adults
What is acute coronary syndrome in older adults?
Acute coronary syndrome (ACS) in older adults encompasses unstable angina and myocardial infarction resulting from reduced coronary blood flow. In elderly patients, ACS is strongly influenced by age-related cardiovascular changes, multimorbidity, and frailty. These factors lead to higher morbidity, mortality, and diagnostic complexity compared with younger populations.
Why does acute coronary syndrome present differently in older adults?
Older adults with ACS frequently experience atypical presentations, including shortness of breath, syncope, fatigue, or acute confusion rather than chest pain. These non-classic symptoms, combined with baseline ECG abnormalities and chronic myocardial injury, make early recognition more challenging and increase the risk of delayed diagnosis.
What are the key AHA recommendations for managing ACS in older adults?
The AHA scientific statement on acute coronary syndrome in the older adult population recommends an individualized, patient-centered approach. Key elements include comprehensive risk assessment, integration of geriatric syndromes, careful selection of pharmacological therapy, appropriate use of revascularization, and shared decision-making based on patient goals and preferences.
How do geriatric syndromes impact outcomes in acute coronary syndrome?
Geriatric syndromes, such as frailty, cognitive impairment, physical disability, and polypharmacy, significantly affect outcomes in older patients with ACS. These conditions increase vulnerability to adverse events, limit tolerance to standard therapies, and influence recovery, making geriatric assessment essential for optimal clinical management.
How should pharmacological therapy be adapted for older adults with ACS?
Pharmacological management of ACS in elderly patients requires careful consideration of age-related changes in pharmacokinetics and pharmacodynamics. Clinicians should adjust doses, simplify treatment regimens, and reassess therapy frequently. These measures reduce bleeding risk, drug interactions, and treatment-related complications while maintaining cardiovascular protection.
How does advanced electrocardiography support ACS diagnosis in older adults?
Advanced electrocardiography plays a critical role in the diagnosis of ACS in older adults. High sampling rates and advanced interpretation algorithms enhance the detection of ischemic changes and arrhythmias. Together, these capabilities support timely and accurate clinical decision-making in accordance with AHA guideline recommendations.