Current Cardiovascular Risk Reports

, Volume 3, Issue 5, pp 355–365 | Cite as

Evolving role of revascularization in older adults with acute coronary syndrome

Article
  • 28 Downloads

Abstract

Revascularization following acute coronary syndrome reduces morbidity and, in some cases, improves survival. Revascularization is part of a care plan that must include optimal medical therapy for secondary prevention and also counseling to promote healthy behaviors. The use of revascularization and guideline-recommended therapies declines as patients age, which may be attributed, in part, to geriatric or “age-associated” vulnerability. Such common geriatric factors include functional decline, comorbid illness, heightened risks of adverse procedural complications or adverse drug reactions, and clinician-perceived decisions regarding risk versus benefit. Patient selection for invasive management must consider patient preferences and risks from age-related multimorbidity. In selected older adults for whom revascularization is favored, advances in percutaneous coronary practices have paralleled improvements in cardiac surgery, both of which are employed to treat older adults in the setting of acute ischemic heart disease.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Boersma E, Mercado N, Poldermans D, et al.: Acute myocardial infarction. Lancet 2003, 361:847–858.PubMedCrossRefGoogle Scholar
  2. 2.
    Fuster V, Badimon L, Badimon JJ, Chesebro JH: The pathogenesis of coronary artery disease and the acute coronary syndrome. N Engl J Med 1992, 326:242–250, 310–318.PubMedGoogle Scholar
  3. 3.
    American Heart Association: Heart Disease and Stroke Statistics-2009 Update. Dallas, Texas: American Heart Association; 2009.Google Scholar
  4. 4.
    Alexander KP, Chen AY, Roe MT, et al.: Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA 2005, 294:3108–3116.PubMedCrossRefGoogle Scholar
  5. 5.
    Wang TY, Chen AY, Alexander KP, et al.: Excess heparin dosing among fibrinolytic-treated patients with ST-segment elevation myocardial infarction. Am J Med 2008, 121:805–810.PubMedCrossRefGoogle Scholar
  6. 6.
    Antman EM, Cohen M, Bernink PJ, et al.: The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000, 284:835–842.PubMedCrossRefGoogle Scholar
  7. 7.
    Boersma E, Pieper KS, Steyerberg EW, et al.: Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation 2000, 101:2557–2567.PubMedGoogle Scholar
  8. 8.
    Eagle KA, Lim MJ, Dabbous OH, et al.: A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post discharge death in an international registry. JAMA 2004, 291:2727–2733.PubMedCrossRefGoogle Scholar
  9. 9.
    Avezum A, Makdisse M, Spencer F, et al.: Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE). Am Heart J 2005, 149:67–73.PubMedCrossRefGoogle Scholar
  10. 10.
    The TIMI IIIB Investigators: Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction results from the TIMI IIIB Trial. Circulation 1994, 89:1545–1556.Google Scholar
  11. 11.
    Boden WE, O’Rourke RA, Crawford MH, et al.; Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators: Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. N Engl J Med 1998, 338:1785–1792.PubMedCrossRefGoogle Scholar
  12. 12.
    FRagmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) Investigators: Longterm low-molecular-mass heparin in unstable coronary artery disease: FRISC II prospective randomised multicentre study. Lancet 1999, 354:701–707.CrossRefGoogle Scholar
  13. 13.
    Fox KA, Poole-Wilson PA, Henderson RA, et al.; Randomized Intervention Trial of unstable Angina Investigators: Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial: Randomised Intervention Trial of unstable Angina. Lancet 2002, 360:743–751.PubMedCrossRefGoogle Scholar
  14. 14.
    Cannon CP, Weintraub WS, Demopoulos LA, et al.; TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy)-Thrombolysis in Myocardial Infarction 18 Investigators: Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001, 344:1879–1887.PubMedCrossRefGoogle Scholar
  15. 15.
    Bach RG, Cannon CP, Weintraub WS, et al.: The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes. Ann Intern Med 2004, 141:186–195.PubMedGoogle Scholar
  16. 16.
    de Winter RJ, Windhausen F, Cornel JH, et al.; Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators: Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005, 353:1095–1104.PubMedCrossRefGoogle Scholar
  17. 17.
    Mehta SR, Cannon CP, Fox KA, et al.: Routine versus selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA 2005, 293:2908–2917.PubMedCrossRefGoogle Scholar
  18. 18.
    Lagerqvist B, Husted S, Kontny F, et al.; Revascularization during InStability in Coronary artery disease-II Investigators: A long-term perspective on the protective effects of an early invasive strategy in unstable coronary artery disease: two-year follow-up of the FRISC-II invasive study. J Am Coll Cardiol 2002, 40:1902–1914.PubMedCrossRefGoogle Scholar
  19. 19.
    Fox KA, Poole-Wilson P, Clayton TC, et al.: 5-Year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA3 randomised trial. Lancet 2005, 366:914–920.PubMedCrossRefGoogle Scholar
  20. 20.
    Hirsch A, Windhausen F, Tijssen JG, et al.: Long-term outcome after an early invasive versus selective invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome and elevated cardiac troponin T (the ICTUS trial): a follow-up study. Lancet 2007, 369:827–835.PubMedCrossRefGoogle Scholar
  21. 21.
    Mehta SR, Granger CB, Boden WE, et al.: Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med 2009, 360:2165–2175.PubMedCrossRefGoogle Scholar
  22. 22.
    Anderson JL, Adams CD, Antman EM, et al.: ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007, 50:e1–e157.PubMedCrossRefGoogle Scholar
  23. 23.
    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. Circulation 2007, 115:2549–2569.PubMedCrossRefGoogle Scholar
  24. 24.
    Antman EM, Anbe DT, Armstrong PW, et al.: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol 2004, 44:E1–E211.PubMedCrossRefGoogle Scholar
  25. 25.
    Bueno H, Martinez-Selles M, Perez-David E, Lopez-Palop R: Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction. Eur Heart J 2005, 26:1705–1711.PubMedCrossRefGoogle Scholar
  26. 26.
    Antman EM, Hand M, Armstrong PW, et al.: 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2008, 51:210–247.PubMedCrossRefGoogle Scholar
  27. 27.
    Alexander KP, Newby LK, Armstrong PW, et al.: Acute coronary care in the elderly, part II. 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, 115:2570–2589.PubMedCrossRefGoogle Scholar
  28. 28.
    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, 145:47–57.PubMedCrossRefGoogle Scholar
  29. 29.
    Ting HH, Bradley EH, Wang Y, et al.: Delay in presentation and reperfusion therapy in ST-elevation myocardial infarction. Am J Med 2008, 121:316–323.PubMedCrossRefGoogle Scholar
  30. 30.
    Hochman JS, Lamas GA, Buller CE, et al.: Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006, 355:2395–2407.PubMedCrossRefGoogle Scholar
  31. 31.
    Skolnick AH, Alexander KP, Chen AY, et al.: Characteristics, management, and outcome of 5, 557 patients age <= 90 years with acute coronary syndrome. J Am Coll Cardiol 2007, 49:1790–1797.PubMedCrossRefGoogle Scholar
  32. 32.
    Subherwal S, Bach RG, Chen AY, et al.: Baseline risk of major bleeding in non-ST-segment elevation myocardial infarction: the CRUSADE bleeding score. Circulation 2009, 119:1873–1882.PubMedCrossRefGoogle Scholar
  33. 33.
    Batchelor WB, Anstrom KJ, Muhlbaier LH, et al.: Contemporary outcome trends in the elderly undergoing percutaneous coronary intervention: results in 7,472 octogenarians. J Am Coll Cardiol 2000, 36:723–730.PubMedCrossRefGoogle Scholar
  34. 34.
    Peterson ED, Alexander KP, Malenka DJ, et al.: Multicenter experience in revascularization of very elderly patients. Am Heart J 2004, 148:486–492.PubMedCrossRefGoogle Scholar
  35. 35.
    Graham MM, Ghali WA, Faris PD, et al.: Survival after coronary revascularization in the elderly. Circulation 2002, 105:2378–2384.PubMedCrossRefGoogle Scholar
  36. 36.
    Chase AJ, Fretz EB, Warburton WP, et al.: Association of the arterial access site at angioplasty with transfusion and mortality: the MORTAL study. Heart 2008, 94:1019–1025.PubMedCrossRefGoogle Scholar
  37. 37.
    Rao SV, Ou FS, Wang TY, et al.: Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention. J Am Coll Cardiol Cardiovasc Interv 2008, 1:379–386.Google Scholar
  38. 38.
    Jolly SS, Amlani S, Hamon M, et al.: Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials of randomized trials. Am Heart J 2009, 157:132–140.PubMedCrossRefGoogle Scholar
  39. 39.
    Roiron C, Sanchez P, Bouzamondo A, et al.: Drug eluting stents: an updated meta-analysis of randomised controlled trials. Heart 2006, 92:641–649.PubMedCrossRefGoogle Scholar
  40. 40.
    Eisenstein EL, Anstrom KJ, Kong DF, et al.: Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 2007, 297:159–168.PubMedCrossRefGoogle Scholar
  41. 41.
    Douglas PS, Brennan JM, Anstrom KJ, et al.: Clinical effectiveness of coronary stents in elderly persons: results from 262,700 Medicare patients in the American College of Cardiology-National Cardiovascular Data Registry. J Am Coll Cardiol 2009, 53:1629–1641.PubMedCrossRefGoogle Scholar
  42. 42.
    Alexander KP, Anstrom KJ, Muhlbaier LH, et al.: Outcomes of cardiac surgery in patients age >= 80 years: results from the National Cardiovascular Network. J Am Coll Cardiol 2000, 35:731–738.PubMedCrossRefGoogle Scholar
  43. 43.
    Peterson ED, Cowper PA, Jollis JG, et al.: Outcomes of coronary artery bypass graft surgery in 24, 461 patients aged 80 years or older. Circulation 1995, 92(Suppl 9):II85–91.PubMedGoogle Scholar
  44. 44.
    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, 360:961–972.PubMedCrossRefGoogle Scholar
  45. 45.
    Rodes-Cabau J, Deblois J, Bertrand OF, et al.: Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians. Circulation 2008, 118:2374–2481.PubMedCrossRefGoogle Scholar
  46. 46.
    Han Y, Wang S, Jing Q, et al.: Comparison of long-term efficacy of the paclitaxel-eluting stent versus the bare-metal stent for treatment of unprotected left main coronary artery disease. Am J Cardiol 2008, 103:194–198.PubMedCrossRefGoogle Scholar
  47. 47.
    Lange RA, Hillis LD: Coronary revascularization in context. N Engl J Med 2009, 360:1024–1025.PubMedCrossRefGoogle Scholar
  48. 48.
    Brinster DR, Byrne M, Rogers CD, et al.: Effectiveness of same day percutaneous coronary intervention followed by minimally invasive aortic valve replacement for aortic stenosis and moderate coronary disease. Am J Cardiol 2006, 98:1501–1503.PubMedCrossRefGoogle Scholar
  49. 49.
    Tabata M, Umakanthan R, Cohn LH, et al.: Early and late outcomes of 1000 minimally invasive aortic valve operations. Eur J Cardiothorac Surg 2008, 33:537–541.PubMedCrossRefGoogle Scholar
  50. 50.
    Reicher B, Poston RS, Mehra MR: Simultaneous “hybrid” percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes. Am Heart J 2008, 155:661–667.PubMedCrossRefGoogle Scholar

Copyright information

© Current Medicine Group, LLC 2009

Authors and Affiliations

  1. 1.Department of Medicine, Division of Cardiology and Geriatrics, Duke Clinical Research Institute, North PavilionDuke University Medical CenterDurhamUSA

Personalised recommendations