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Atherosclerotic Cardiovascular Disease in Older Adults

  • Cardiovascular Disease in the Elderly (M Chen, Section Editor)
  • Published:
Current Geriatrics Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Atherosclerotic coronary disease is a major cause of morbidity and mortality in older adults. The purposes of this review are to summarize our current knowledge about best practices in the management of coronary artery disease in this population and to highlight remaining gaps in our understanding.

Recent Findings

Elderly patients are far less likely than their younger counterparts to receive guideline-based care after presenting with an acute coronary syndrome (ACS). However, despite some attenuation of benefit with increasing age, recent studies have shown improved outcomes with an early invasive strategy, even amongst patients over 90 years of age.

Summary

The best currently available evidence suggests numerous scenarios in which elderly patients may benefit from coronary revascularization in addition to medical therapy. In particular, patients with refractory angina and those who present with ACS can expect improvements in quality of life and mortality, respectively, with guideline-directed therapy.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Celermajer DS, Sorensen KE, Spiegelhalter DJ, Georgakopoulos D, Robinson J, Deanfield JE. Aging is associated with endothelial dysfunction in healthy men years before the age-related decline in women. J Am Coll Cardiol. 1994;24(2):471–6.

    Article  CAS  PubMed  Google Scholar 

  2. Afilalo J, Mottillo S, Eisenberg MJ, et al. Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity. Circ Cardiovasc Qual Outcomes. 2012;5(2):222–8.

    Article  PubMed  Google Scholar 

  3. •• Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115(19):2549–69. These are the most recent guidelines for management of NSTEMI in elderly patients

    Article  PubMed  Google Scholar 

  4. Yazdanyar A, Newman AB. The burden of cardiovascular disease in the elderly: morbidity, mortality, and costs. Clin Geriatr Med. 2009;25(4):563–77. vii

    Article  PubMed  PubMed Central  Google Scholar 

  5. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38–360.

    Article  PubMed  Google Scholar 

  6. Fleg JL, Forman DE, Berra K, et al. Secondary prevention of atherosclerotic cardiovascular disease in older adults: a scientific statement from the American Heart Association. Circulation. 2013;128(22):2422–46.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Dai X, Busby-Whitehead J, Forman DE, Alexander KP. Stable ischemic heart disease in the older adults. J Geriatr Cardiol. 2016;13(2):109–14.

    PubMed  PubMed Central  Google Scholar 

  8. Montilla Padilla I, Martín-Asenjo R, Bueno H. Management of acute coronary syndromes in geriatric patients. Heart Lung Circ. 2017;26(2):107–13.

    Article  PubMed  Google Scholar 

  9. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139–228.

    Article  PubMed  Google Scholar 

  10. Bagnall AJ, Goodman SG, Fox KA, et al. Influence of age on use of cardiac catheterization and associated outcomes in patients with non-ST-elevation acute coronary syndromes. Am J Cardiol. 2009;103(11):1530–6.

    Article  PubMed  Google Scholar 

  11. Skolnick AH, Alexander KP, Chen AY, et al. Characteristics, management, and outcomes of 5,557 patients age > or =90 years with acute coronary syndromes: results from the CRUSADE initiative. J Am Coll Cardiol. 2007;49(17):1790–7.

    Article  PubMed  Google Scholar 

  12. • Savonitto S, Cavallini C, Petronio AS, et al. Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial. JACC Cardiovasc Interv. 2012;5(9):906–16. This is one of the only randomized controlled trials of management of NSTEMI specifically addressing an elderly population

    Article  PubMed  Google Scholar 

  13. • Tegn N, Abdelnoor M, Aaberge L, 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(10023):1057–65. This is one of the only randomized controlled trials of management of NSTEMI specifically addressing an elderly population

    Article  PubMed  Google Scholar 

  14. Cerqueira MD, Maynard C, Ritchie JL, Davis KB, Kennedy JW. Long-term survival in 618 patients from the Western Washington Streptokinase in Myocardial Infarction trials. J Am Coll Cardiol. 1992;20(7):1452–9.

    Article  CAS  PubMed  Google Scholar 

  15. White HD, Barbash GI, Califf RM, et al. Age and outcome with contemporary thrombolytic therapy. Results from the GUSTO-I trial. Global utilization of streptokinase and TPA for occluded coronary arteries trial. Circulation. 1996;94(8):1826–33.

    Article  CAS  PubMed  Google Scholar 

  16. Stone GW, Grines CL, Browne KF, et al. Predictors of in-hospital and 6-month outcome after acute myocardial infarction in the reperfusion era: the Primary Angioplasty in Myocardial Infarction (PAMI) trail. J Am Coll Cardiol. 1995;25(2):370–7.

    Article  CAS  PubMed  Google Scholar 

  17. investigators G. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993;329(10):673–82.

    Article  Google Scholar 

  18. Grines C, Patel A, Zijlstra F, et al. Primary coronary angioplasty compared with intravenous thrombolytic therapy for acute myocardial infarction: six-month follow up and analysis of individual patient data from randomized trials. Am Heart J. 2003;145(1):47–57.

    Article  CAS  PubMed  Google Scholar 

  19. Boersma E. Group PCAvT. Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Eur Heart J. 2006;27(7):779–88.

    Article  PubMed  Google Scholar 

  20. Eagle KA, Goodman SG, Avezum A, et al. Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE). Lancet. 2002;359(9304):373–7.

    Article  PubMed  Google Scholar 

  21. Gale CP, Cattle BA, Woolston A, et al. Resolving inequalities in care? Reduced mortality in the elderly after acute coronary syndromes. The Myocardial Ischaemia National Audit Project 2003-2010. Eur Heart J. 2012;33(5):630–9.

    Article  PubMed  Google Scholar 

  22. •• Alexander KP, Newby LK, Armstrong PW, et al. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115(19):2570–89. These are the most recent guidelines for management of STEMI in elderly patients

    Article  PubMed  Google Scholar 

  23. Zaman MJ, Stirling S, Shepstone L, et al. The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP). Eur Heart J. 2014;35(23):1551–8.

    Article  PubMed  Google Scholar 

  24. Katsikis A, Theodorakos A, Kouzoumi A, Papaioannou S, Drosatos A, Koutelou M. Prognostic value of the Duke treadmill score in octogenarians undergoing myocardial perfusion imaging. Atherosclerosis. 2014;236(2):373–80.

    Article  CAS  PubMed  Google Scholar 

  25. Katsikis A, Theodorakos A, Papaioannou S, et al. Long-term prognostic value of myocardial perfusion imaging in octogenarians able to undergo treadmill exercise stress testing. J Nucl Cardiol. 2014;21(6):1213–22.

    Article  PubMed  Google Scholar 

  26. Teo KK, Yusuf S, Furberg CD. Effects of prophylactic antiarrhythmic drug therapy in acute myocardial infarction. An overview of results from randomized controlled trials. JAMA. 1993;270(13):1589–95.

    Article  CAS  PubMed  Google Scholar 

  27. Collaboration AT. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324(7329):71–86.

    Article  PubMed Central  Google Scholar 

  28. Investigators T. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial. Lancet. 2001;358(9286):951–7.

    Article  Google Scholar 

  29. Graham MM, Norris CM, Galbraith PD, Knudtson ML, Ghali WA, Investigators A. Quality of life after coronary revascularization in the elderly. Eur Heart J. 2006;27(14):1690–8.

    Article  PubMed  Google Scholar 

  30. Favaloro RG. Saphenous vein autograft replacement of severe segmental coronary artery occlusion: operative technique. Ann Thorac Surg. 1968;5(4):334–9.

    Article  CAS  PubMed  Google Scholar 

  31. Meraj PM, Jauhar R, Singh A. Bare metal stents versus drug eluting stents: where do we stand in 2015? Curr Treat Options Cardiovasc Med. 2015;17(8):393.

    Article  PubMed  Google Scholar 

  32. Mullany CJ, Mock MB, Brooks MM, et al. Effect of age in the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial. Ann Thorac Surg. 1999;67(2):396–403.

    Article  CAS  PubMed  Google Scholar 

  33. Ramanathan KB, Weiman DS, Sacks J, et al. Percutaneous intervention versus coronary bypass surgery for patients older than 70 years of age with high-risk unstable angina. Ann Thorac Surg. 2005;80(4):1340–6.

    Article  PubMed  Google Scholar 

  34. Chieffo A, Morici N, Maisano F, et al. Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience. Circulation. 2006;113(21):2542–7.

    Article  CAS  PubMed  Google Scholar 

  35. Lee MS, Kapoor N, Jamal F, et al. Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease. J Am Coll Cardiol. 2006;47(4):864–70.

    Article  CAS  PubMed  Google Scholar 

  36. Palmerini T, Barlocco F, Santarelli A, et al. A comparison between coronary artery bypass grafting surgery and drug eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged > or =75 years). Eur Heart J. 2007;28(22):2714–9.

    Article  PubMed  Google Scholar 

  37. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961–72.

    Article  CAS  PubMed  Google Scholar 

  38. Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013;381(9867):629–38.

    Article  PubMed  Google Scholar 

  39. Morice MC, Serruys PW, Kappetein AP, et al. Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial. Circulation. 2014;129(23):2388–94.

    Article  PubMed  Google Scholar 

  40. Stone GW, Sabik JF, Serruys PW, et al. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 2016;375(23):2223–35.

    Article  CAS  PubMed  Google Scholar 

  41. Mäkikallio T, Holm NR, Lindsay M, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388(10061):2743–52.

    Article  PubMed  Google Scholar 

  42. Hueb W, Lopes N, Gersh BJ, et al. Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation. 2010;122(10):949–57.

    Article  PubMed  Google Scholar 

  43. Bangalore S, Guo Y, Samadashvili Z, Blecker S, Hannan EL. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction: everolimus-eluting stents versus coronary artery bypass graft surgery. Circulation. 2016;133(22):2132–40.

    Article  CAS  PubMed  Google Scholar 

  44. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56.

    Article  CAS  PubMed  Google Scholar 

  45. Afilalo J, Alexander KP, Mack MJ, et al. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol. 2014;63(8):747–62.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Columbia New York-Presbyterian Hospital, 161 Fort Washington Avenue, 6th Floor, New York, NY, 10032, USA

    Christine J. Chung & Philip Green

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  1. Christine J. Chung
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  2. Philip Green
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Correspondence to Christine J. Chung.

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Philip Green and Christine Chung declare no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Cardiovascular Disease in the Elderly

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Chung, C.J., Green, P. Atherosclerotic Cardiovascular Disease in Older Adults. Curr Geri Rep 6, 273–278 (2017). https://doi.org/10.1007/s13670-017-0225-x

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  • DOI: https://doi.org/10.1007/s13670-017-0225-x

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