Managing acute coronary syndrome: Protocols and best practices
A review article for emergency medical services, pharmacists, and health informatics
Keywords:
acute coronary syndrome, elderly, invasive management, antithrombotic therapy, risk assessment, ECG, coronary angiographyAbstract
Background: Acute Coronary Syndrome (ACS) management in elderly patients poses unique challenges due to age-related physiological changes and comorbidities. Prompt and accurate assessment and management are crucial to prevent adverse outcomes. Aim: This review aims to evaluate current protocols and best practices for managing ACS in elderly patients, focusing on diagnostic strategies, treatment options, and considerations for invasive and antithrombotic therapies. Review also aimed to improve the future responses via pharmacists, emergency services, and health information systems. Methods: The review synthesizes guidelines and recent research on the management of ACS in elderly populations. It highlights the importance of early ECG interpretation, risk assessment, and tailored therapeutic interventions, including antithrombotic therapies and invasive procedures. Results: Key findings include the necessity for early and precise diagnostic evaluation, including ECG and troponin tests. Invasive management strategies, such as early coronary angiography, have shown benefits but must be carefully weighed against risks in very elderly patients. Antithrombotic therapy requires dose adjustments based on renal function and bleeding risks. Radial access is preferred during PCI to minimize bleeding complications. The review also discusses ongoing research in optimizing antithrombotic therapies for the elderly.
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Ibañez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the Management of Acute Myocardial Infarction in Patients Presenting with ST-segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. Epub ahead of print 26 August 2017.
Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37: 267–315. DOI: https://doi.org/10.1093/eurheartj/ehv320
Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc 2009; 84: 917–938. DOI: https://doi.org/10.4065/84.10.917
Solomon CG, Lee TH, Cook EF, et al. Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: the Multicenter Chest Pain Study experience. Am J Cardiol 1989; 63: 772–776. DOI: https://doi.org/10.1016/0002-9149(89)90040-4
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC Guidelines on the management of stable coronary artery disease: the Task Force on the Management of Stable Coronary Artery Disease of the European Society of Cardiology. Eur Heart J 2013; 34: 2949–3003. DOI: https://doi.org/10.1093/eurheartj/eht296
Jain S, Ting HT, Bell M, et al. Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. Am J Cardiol 2011; 107: 1111–1116. DOI: https://doi.org/10.1016/j.amjcard.2010.12.007
Kontos MC, Aziz HA, Chau VQ, et al. Outcomes in patients with chronicity of left bundle-branch block with possible acute myocardial infarction. Am Heart J 2011; 161: 698–704. DOI: https://doi.org/10.1016/j.ahj.2011.01.008
Bueno H, ed. ACCA Clinical Decision-Making Toolkit, Edition 2017. Available at: https://www.escardio.org/Education/Practice-Tools/ACCA-Toolkit
Beygui F, Castren M, Brunetti ND, et al. Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC. Eur Heart J Acute Cardiovasc Care 2015. Epub ahead of print: pii: 2048872615604119. DOI: https://doi.org/10.1177/2048872615604119
Claeys MJ, Ahrens I, Sinnaeve P, et al. The organisation of chest pain units: position paper of the Acute Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care 2017; 6: 203–211. DOI: https://doi.org/10.1177/2048872617695236
Damman P, Clayton T, Wallentin L, et al. Effects of age on long-term outcomes after a routine invasive or selective invasive strategy in patients presenting with non-ST segment elevation acute coronary syndromes: a collaborative analysis of individual data from the FRISC II – ICTUS – RITA-3 (FIR) trials. Heart 2012; 98: 207–213. DOI: https://doi.org/10.1136/heartjnl-2011-300453
Angeli F, Verdecchia P, Savonitto S, et al. Early invasive versus selectively invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: impact of age. Catheter Cardiovasc Interv 2014; 83: 686–701. DOI: https://doi.org/10.1002/ccd.25307
Savonitto S, Cavallini C, Petronio AS, et al., .; for the Italian Elderly ACS Trial Investigators. Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome a randomized controlled trial. J Am Coll Cardiol Interv 2012; 5: 906–916. DOI: https://doi.org/10.1016/j.jcin.2012.06.008
Tegn N, Abdelnoor M, Aaberge A, et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial. Lancet 2016; 387: 1057–1065. DOI: https://doi.org/10.1016/S0140-6736(15)01166-6
Armaganijan LV, Alexander KP, Huang Z, et al. Effect of age on efficacy and safety of vorapaxar in patients with non-ST-segment elevation acute coronary syndrome: insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial. Am Heart J 2016; 178: 176–184. DOI: https://doi.org/10.1016/j.ahj.2016.05.012
Leonardi S, Bhatt DL. Practical considerations for cangrelor use in patients with acute coronary syndromes. Eur Heart J Acute Cardiovasc Care. Epub ahead of print 1 June 2017. DOI: https://doi.org/10.1177/2048872617707960
Alnasser SM, Bagai A, Jolly SS, et al. Transradial approach for coronary angiography and intervention in the elderly: a meta-analysis of 777,841 patients. Int J Cardiol 2017; 228: 45–51. DOI: https://doi.org/10.1016/j.ijcard.2016.11.207
Costa F, van Klaveren D, James S, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet 2017; 389: 1025–1034. DOI: https://doi.org/10.1016/S0140-6736(17)30397-5
Yeh RW, Secemsky EA, Kereiakes DJ, et al. Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention. JAMA 2016; 315: 1735–1749. DOI: https://doi.org/10.1001/jama.2016.3775
Leonardi S, Frigoli E, Rothenbühler M, et al. Bivalirudin or unfractionated heparin in patients with acute coronary syndromes managed invasively with and without ST elevation (MATRIX): randomised controlled trial. BMJ 2016; 354: i4935. DOI: https://doi.org/10.1136/bmj.i4935
Ferri LA, Morici N, Grosseto D, et al. A comparison of reduced-dose prasugrel and standard-dose clopidogrel in elderly patients with acute coronary syndromes undergoing early percutaneous revascularization: design and rationale of the randomized Elderly-ACS 2 study. Am Heart J 2016; 181: 101–106. DOI: https://doi.org/10.1016/j.ahj.2016.08.010
Qaderdan K, Ishak M, Heestermans AA, et al. Ticagrelor or prasugrel versus clopidogrel in elderly patients with an acute coronary syndrome: optimization of antiplatelet treatment in patients 70 years and older – rationale and design of the POPular AGE study. Am Heart J 2015; 170: 981–985. DOI: https://doi.org/10.1016/j.ahj.2015.07.030
Rocca WA, Boyd CM, Grossardt BR, et al. Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity. Mayo Clin Proc 2014; 89: 1336–1349. DOI: https://doi.org/10.1016/j.mayocp.2014.07.010
Afilalo J, Alexander KP, Mack MJ, et al. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol 2014; 63: 747–762. DOI: https://doi.org/10.1016/j.jacc.2013.09.070
Singh M, Stewart R, White H. Importance of frailty in patients with cardiovascular disease. Eur Heart J 2014; 35: 1726–1731. DOI: https://doi.org/10.1093/eurheartj/ehu197
Alonso Salinas GL, Sanmartin M, Pascual Izco M, et al. Frailty is an independent prognostic marker in elderly patients with myocardial infarction. Clin Cardiol 2017; 40: 925–931. DOI: https://doi.org/10.1002/clc.22749
Denfeld QE, Winters-Stone K, Mudd JO, et al. The prevalence of frailty in heart failure: a systematic review and meta-analysis. Int J Cardiol 2017; 236: 283–289. DOI: https://doi.org/10.1016/j.ijcard.2017.01.153
Bibas L, Levi M, Touchette J, et al. Implications of frailty in elderly patients with electrophysiological conditions. JACC: Clin Electrophysiol 2016; 2: 288–294. DOI: https://doi.org/10.1016/j.jacep.2016.04.013
Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173: 489–495. DOI: https://doi.org/10.1503/cmaj.050051
Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med 2011; 27: 17–26. DOI: https://doi.org/10.1016/j.cger.2010.08.008
Rich MW, Chyun DA, Skolnick AH, et al. Knowledge gaps in cardiovascular care of the older adult population: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society. J Am Coll Cardiol 2016; 67: 2419–2440. DOI: https://doi.org/10.1016/j.jacc.2016.03.004
Le Guen J, Boumendil A, Guidet B, et al. Are elderly patients’ opinions sought before admission to an intensive care unit? Results of the ICE-CUB study. Age Ageing 2016; 45: 303–309. DOI: https://doi.org/10.1093/ageing/afv191
Zweibel NR, Cassel CK. Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies. Gerontologist 1989; 29: 615–621. DOI: https://doi.org/10.1093/geront/29.5.615
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