Skip to main content

Advertisement

SpringerLink
Log in

Acute coronary syndrome in very elderly patients—a real-world experience

  • Original Article
  • Published:
Heart and Vessels Aims and scope Submit manuscript

Abstract

Very elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes (ACS). Notably, age represents both a proxy of frailty and an exclusion criterion in clinical randomized trials, which probably contributes to lack of data and undertreatment of real-world elderly patients. The aim of the study is to describe patterns of treatment and outcome of very elderly patients with ACS. All consecutive patients aged ≥ 80 years old (yo) admitted between January 2017 and December 2019 with ACS were included. The primary endpoint was in-hospital occurrence of major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, new onset cardiogenic shock, definite/probable stent thrombosis, and ischemic stroke. The secondary endpoints were in-hospital incidence of Thrombolysis in Myocardial Infarction (TIMI) major/minor bleedings, contrast-induced nephropathy (CIN), six-month all-cause mortality, and unplanned readmission. One hundred ninety-three patients (mean age 84.1 ± 3.5 yo, 46% females) were included, of whom 86 (44.6%), 79 (40.9%), and 28 (14.5%) presented with ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA), respectively. The vast majority of patients received an invasive strategy, with 92.7% undergoing coronary angiography and 84.4% to percutaneous coronary intervention (PCI). Aspirin was administered to 180 (93.3%) patients, clopidogrel to 89 (46.1%) patients, and ticagrelor to 85 (44%) patients. In-hospital MACE occurred in 29 patients (15.0%), whereas 3 (1.6%) and 12 patients (7.2%) experienced in-hospital TIMI major and TIMI minor bleeding, respectively. Of the overall population, 177 (91.7%) were discharged alive. After discharge, 11 patients (6.2%) died of all-cause death, whereas 42 patients (23.7%) required a new hospitalization within six months. Invasive strategy of ACS in elderly patients seems safe and effective. Six-month new hospitalization appears inevitably related to age.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data availability

The study database will be available for research or other ad adequate requests contacting the corresponding author.

References

  1. Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, Maurer MS, McClurken JB, Resnick BM, Shen WK, Tirschwell DL; American Heart Association Older Populations Committee of the Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council; American College of Cardiology; and American Geriatrics Society (2016) 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 67(20):2419–2440

    Article  Google Scholar 

  2. Leonardi S, Bueno H, Ahrens I, Hassager C, Bonnefoy E, Lettino M (2018) Optimised care of elderly patients with acute coronary syndrome. Eur Heart J Acute Cardiovasc Care 7(3):287–295

    Article  PubMed  Google Scholar 

  3. Li L, Geraghty OC, Mehta Z, Rothwell PM; Oxford Vascular Study (2017) Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: a population-based cohort study. Lancet 390(10093):490–499

    Article  Google Scholar 

  4. Savonitto S, Cavallini C, Petronio AS, Murena E, Antonicelli R, Sacco A, Steffenino G, Bonechi F, Mossuti E, Manari A, Tolaro S, Toso A, Daniotti A, Piscione F, Morici N, Cesana BM, Jori MC, De Servi S, Italian Elderly ACS, Investigators T (2012) Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial. JACC Cardiovasc Interv 5(9):906–916

    Article  PubMed  Google Scholar 

  5. Capranzano P, Angiolillo DJ (2020) Ticagrelor or Clopidogrel in elderly patients with myocardial infarction: when the choice makes the difference. Circulation 142(18):1709–1712

    Article  PubMed  Google Scholar 

  6. Capranzano P, Angiolillo DJ (2021) Antithrombotic management of elderly patients with coronary artery disease. JACC Cardiovasc Interv 14(7):723–738

    Article  PubMed  Google Scholar 

  7. Holzmann MJ, Siddiqui AJ (2020) Outcome of percutaneous coronary intervention during non-st-segment-elevation myocardial infarction in elderly patients with chronic kidney disease. J Am Heart Assoc 9(12):e015084

    Article  PubMed  PubMed Central  Google Scholar 

  8. Costa F, van Klaveren D, James S, Heg D, Räber L, Feres F, Pilgrim T, Hong MK, Kim HS, Colombo A, Steg PG, Zanchin T, Palmerini T, Wallentin L, Bhatt DL, Stone GW, Windecker S, Steyerberg EW, Valgimigli M; PRECISE-DAPT Study Investigators (2017) 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 389(10073):1025–1034

    Article  Google Scholar 

  9. Fox KA, Eagle KA, Gore JM, Steg PG, Anderson FA, GRACE and GRACE2 Investigators (2010) The global registry of acute coronary events, 1999 to 2009–GRACE. Heart 96(14):1095–1101

    Article  CAS  PubMed  Google Scholar 

  10. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD; ESC Scientific Document Group (2019) Fourth universal definition of myocardial infarction (2018). Eur Heart J 40(3):237–269

    Article  Google Scholar 

  11. Garcia-Garcia HM, McFadden EP, Farb A, Mehran R, Stone GW, Spertus J, Onuma Y, Morel MA, van Es GA, Zuckerman B, Fearon WF, Taggart D, Kappetein AP, Krucoff MW, Vranckx P, Windecker S, Cutlip D, Serruys PW (2018) Academic research consortium standardized end point definitions for coronary intervention trials: the academic research consortium-2 consensus document. Circulation 137(24):2635–2650

    Article  PubMed  Google Scholar 

  12. Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM; ESC Scientific Document Group (2021) 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 42(14):1289–1367

    Article  Google Scholar 

  13. Baran DA, Grines CL, Bailey S, Burkhoff D, Hall SA, Henry TD, Hollenberg SM, Kapur NK, O’Neill W, Ornato JP, Stelling K, Thiele H, van Diepen S, Naidu SS (2019) SCAI clinical expert consensus statement on the classification of cardiogenic shock: this document was endorsed by the American College of Cardiology (ACC), the American heart association (AHA), the society of critical care medicine (SCCM), and the society of thoracic surgeons (STS) in April 2019. Catheter Cardiovasc Interv 94(1):29–37

    PubMed  Google Scholar 

  14. Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, Elkind MS, George MG, Hamdan AD, Higashida RT, Hoh BL, Janis LS, Kase CS, Kleindorfer DO, Lee JM, Moseley ME, Peterson ED, Turan TN, Valderrama AL, Vinters HV, American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Peripheral Vascular Disease; Council on Nutrition, Physical Activity and Metabolism (2013) An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 44(7):2064–2089

    Article  PubMed  Google Scholar 

  15. Mehran R, Nikolsky E (2006) Contrast-induced nephropathy: definition, epidemiology, and patients at risk. Kidney Int Suppl 100:S11–S15

    Article  CAS  Google Scholar 

  16. Mehta SR, Yusuf S, Peters RJ, Bertrand ME, Lewis BS, Natarajan MK, Malmberg K, Rupprecht H, Zhao F, Chrolavicius S, Copland I, Fox KA (2001) Clopidogrel in unstable angina to prevent recurrent events trial (CURE) investigators effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 358(9281):527–533

    Article  CAS  PubMed  Google Scholar 

  17. Montalescot G, Wiviott SD, Braunwald E, Murphy SA, Gibson CM, McCabe CH, Antman EM, TRITON-TIMI 38 investigators (2009) Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet 373(9665):723–731

    Article  CAS  PubMed  Google Scholar 

  18. Kaura A, Sterne JAC, Trickey A, Abbott S, Mulla A, Glampson B, Panoulas V, Davies J, Woods K, Omigie J, Shah AD, Channon KM, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs FW, O’Sullivan M, Lord GM, Melikian N, Johnson T, Francis DP, Shah AM, Perera D, Kharbanda R, Patel RS, Mayet J (2020) Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data. Lancet 396(10251):623–634

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO; ESC Scientific Document Group (2019) 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 40(2):87–165

    Article  Google Scholar 

  20. Bueno H (2015) Medical management: the dark side of acute coronary syndromes. Eur Heart J Cardiovasc Pharmacother 1(3):179–181

    Article  PubMed  Google Scholar 

  21. Fox KA, Anderson FA Jr, Dabbous OH, Steg PG, López-Sendón J, Van de Werf F, Budaj A, Gurfinkel EP, Goodman SG, Brieger D, GRACE investigators (2007) Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The global registry of acute coronary events (GRACE). Heart 93(2):177–182

    Article  CAS  PubMed  Google Scholar 

  22. Bauer T, Möllmann H, Weidinger F, Zeymer U, Seabra-Gomes R, Eberli F, Serruys P, Vahanian A, Silber S, Wijns W, Hochadel M, Nef HM, Hamm CW, Marco J, Gitt AK (2011) Predictors of hospital mortality in the elderly undergoing percutaneous coronary intervention for acute coronary syndromes and stable angina. Int J Cardiol 151(2):164–169

    Article  PubMed  Google Scholar 

  23. Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, Neumann FJ, Ardissino D, De Servi S, Murphy SA, Riesmeyer J, Weerakkody G, Gibson CM, Antman EM, TRITON-TIMI 38 Investigators (2007) Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 357(20):2001–2015

    Article  CAS  PubMed  Google Scholar 

  24. Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, Horrow J, Husted S, James S, Katus H, Mahaffey KW, Scirica BM, Skene A, Steg PG, Storey RF, Harrington RA, Investigators PLATO, Freij A, Thorsén M (2009) Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 361(11):1045–1057

    Article  CAS  PubMed  Google Scholar 

  25. Husted S, James S, Becker RC, Horrow J, Katus H, Storey RF, Cannon CP, Heras M, Lopes RD, Morais J, Mahaffey KW, Bach RG, Wojdyla D, Wallentin L, PLATO study group (2012) Ticagrelor versus clopidogrel in elderly patients with acute coronary syndromes: a substudy from the prospective randomized PLATelet inhibition and patient Outcomes (PLATO) trial. Circ Cardiovasc Qual Outcomes 5(5):680–688

    Article  PubMed  Google Scholar 

  26. Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN; ESC Scientific Document Group; ESC Committee for Practice Guidelines (CPG); ESC National Cardiac Societies (2018) 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: the task force for dual antiplatelet therapy in coronary artery disease of the European society of cardiology (ESC) and of the European association for cardio-thoracic surgery (EACTS). Eur Heart J 39(3):213–260

    Article  Google Scholar 

  27. Bianco M, Careggio A, Biolè CA, Quadri G, Quiros A, Raposeiras-Roubin S, Abu-Assi E, Kinnaird T, Ariza-Solè A, Liebetrau C, Manzano-Fernàndez S, Boccuzzi G, Henriques JPS, Spirito A, Templin C, Wilton SB, Velicki L, Correia L, Rognoni A, Ugo F, Nunez-Gil I, Fujii T, Durante A, Song X, Kawaji T, Alexopoulos D, Huczek Z, Gonzàlez Juanatey JR, Nie SP, Kawashiri MA, Morbiducci U, Dominguez-Rodriguez A, Destefanis P, Luciano A, De Ferrari GM, Varbella F, Montagna L, D’Ascenzo F, Cerrato E (2021) Ticagrelor or Clopidogrel after an acute coronary syndrome in the elderly: a propensity score matching analysis from 16,653 patients treated with PCI included in two large multinational registries. Cardiovasc Drugs Ther 35(6):1171–1182

    Article  CAS  PubMed  Google Scholar 

  28. Akkaif MA, Sha’aban A, Daud NAA, Yunusa I, Ng ML, Sk Abdul Kader MA, Noor DAM, Ibrahim B (2021) Coronary heart disease (CHD) in elderly patients: which drug to choose, Ticagrelor and Clopidogrel? a systematic review and meta-analysis of randomized controlled trials. J Cardiovasc Dev Dis 8(10):123

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Kruchinova S, Raff SA, Kosmacheva ED (2020) Analysis of hospital mortality in acute coronary syndrome in elderly and long-lived patients. Eur Heart J 41(946):1644

    Google Scholar 

  30. Murphy JC, Kozor RA, Figtree G, Hansen PS, Rasmussen HH, Ward MR, Nelson GI, Bhindi R (2012) Procedural and in-patient outcomes in patients aged 80 years or older undergoing contemporary primary percutaneous coronary intervention. EuroIntervention 8(8):912–919

    Article  PubMed  Google Scholar 

  31. Valente S, Lazzeri C, Salvadori C, Chiostri M, Giglioli C, Poli S, Gensini GF (2008) Effectiveness and safety of routine primary angioplasty in patients aged > or =85 years with acute myocardial infarction. Circ J 72(1):67–70

    Article  PubMed  Google Scholar 

  32. Tang EW, Wong CK, Herbison P (2007) Global registry of acute coronary events (GRACE) hospital discharge risk score accurately predicts long-term mortality post acute coronary syndrome. Am Heart J 153(1):29–35

    Article  PubMed  Google Scholar 

  33. Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, Van De Werf F, Avezum A, Goodman SG, Flather MD, Fox KA (2003) Global registry of acute coronary events investigators. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 163(19):2345–2353

    Article  PubMed  Google Scholar 

  34. Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, Mautner B, Corbalan R, Radley D, Braunwald E (2000) The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 284(7):835–842

    Article  CAS  PubMed  Google Scholar 

  35. Investigators TRIUMPH, Alexander JH, Reynolds HR, Stebbins AL, Dzavik V, Harrington RA, Van de Werf F, Hochman JS (2007) Effect of tilarginine acetate in patients with acute myocardial infarction and cardiogenic shock: the TRIUMPH randomized controlled trial. JAMA 297(15):1657–1666

    Article  Google Scholar 

  36. Khera R, Jain S, Pandey A, Agusala V, Kumbhani DJ, Das SR, Berry JD, de Lemos JA, Girotra S (2017) Comparison of readmission rates after acute myocardial infarction in 3 patient age groups (18 to 44, 45 to 64, and ≥65 Years) in the United States. Am J Cardiol 120(10):1761–1767

    Article  PubMed  PubMed Central  Google Scholar 

  37. Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM; ESC Scientific Document Group (2021) 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 42(35):3427–3520

    Article  Google Scholar 

Download references

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Author information

Author notes

  1. Matteo Bianco and Filiberto Fausto Mottola have equally contributed to this paper.

Authors and Affiliations

  1. Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy

    Matteo Bianco & Enrico Cerrato

  2. Chair of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”-Monaldi Hospital, Naples, Italy

    Filiberto Fausto Mottola

  3. Division of Cardiology, S. Croce and Carle Hospital, Via Michele Coppino, 26, 12100, Cuneo, Italy

    Francesca Giordana, Sebastian Cinconze, Giorgio Baralis, Alison Verra & Roberta Rossini

  4. Division of Cardiology, Ordine Mauriziano Di Torino Hospital, Turin, Italy

    Giuseppe Musumeci

Authors
  1. Matteo Bianco
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Filiberto Fausto Mottola
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Enrico Cerrato
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Francesca Giordana
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sebastian Cinconze
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Giorgio Baralis
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Alison Verra
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Giuseppe Musumeci
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Roberta Rossini
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MB, FF M, and FG have given substantial contributions to the conception and the design of the manuscript, and SC, AV, and EC to acquisition, analysis, and interpretation of the data. All the authors have participated in drafting the manuscript. GM and RR revised it critically. All the authors read and approved the final version of this manuscript.

Corresponding author

Correspondence to Roberta Rossini.

Ethics declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

This study was performed according to the S. Croce and Carle Hospital in Cuneo, Italy, Review Board guidance and conducted in accordance with the Declaration of Helsinki and its later amendments.

Consent to participate

Informed consent was obtained from all individual participants included in this study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bianco, M., Mottola, F.F., Cerrato, E. et al. Acute coronary syndrome in very elderly patients—a real-world experience. Heart Vessels 38, 1019–1027 (2023). https://doi.org/10.1007/s00380-023-02260-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00380-023-02260-x

Keyword

Search

Navigation