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Medical and ethical approach to acute
coronary management of elderly patients –
practical advice for primary care physicians
Medyczne i etyczne aspekty postępowania ze starszymi pacjentami
z ostrymi zespołami wieńcowymi – praktyczne rady dla lekarzy
podstawowej opieki zdrowotnej
Katarzyna Anna Rygiel
Key words:
acute coronary
syndromes (ACS),
elderly population,
revascularization,
risk–benefit ratio, left
ventricular ejection
fraction (LVEF), sudden
cardiac death (SCD)
Słowa kluczowe:
ostry zespół wieńcowy
(ACS), populacja
starszych pacjentów,
rewaskularyzacja,
proporcja korzyści
i ryzyka, frakcja
wyrzutowa lewej komory
(LVEF), nagła śmierć
sercowa (SCD)
Department of Family
Medicine, Medical University
of Silesia in Zabrze
Katarzyna Anna Rygiel, MD, PhD
Member of research
and education team
Abstract: Older age is an important risk factor that can determine outcomes in patients with acute
coronary syndromes (ACS). However, research reports related to the practical use of invasive procedures and pharmacological therapies, reveal a lower use of these treatments among elderly patients.
To facilitate an integrated approach to this problem in primary care setting, this article focuses on basic
medical and ethical aspects of ACS. It offers some practical suggestions, how to improve therapeutic
strategies for elderly patients, for family and primary care physicians, taking care of geriatric patients.
It also focuses on management of elderly women with a high left ventricular ejection fraction (LVEF),
who can have an elevated mortality risk, comparing to the ones with ACS, but with a normal LVEF. The
article also highlights the main goal of the acute coronary management, which is to minimize risks, and
to augment treatment benefits, within the individualized clinical, psycho-social, and family context.
Streszczenie: Starszy wiek stanowi istotny czynnik ryzyka, determinujący rokowanie wśród
pacjentów z ostrymi zespołami wieńcowymi (acute coronary syndrome, ACS). Jednakże raporty
z badań klinicznych, dotyczące praktycznego zastosowania inwazyjnych procedur wieńcowych i terapii farmakologicznych, wykazują mniejszą częstość stosowania tego typu leczenia w starszej grupie
pacjentów. Aby przybliżyć zintegrowany sposób podejścia klinicznego, w celu lepszego rozwiązania
tego problemu w warunkach podstawowej opieki zdrowotnej (POZ), artykuł koncentruje się na zasadniczych medycznych i etycznych aspektach ACS oraz przedstawia praktyczne sugestie – jak poprawić strategie lecznicze w grupie geriatrycznych pacjentów, pozostających pod opieką lekarzy rodzinnych i praktyków POZ. Przeanalizowano także schemat postępowania w przypadku starszych kobiet
z wysoką frakcją wyrzutową lewej komory serca (left ventricular ejection fraction, LVEF), wśród których
może występować podwyższone ryzyko śmiertelności, w porównaniu z pacjentkami z ACS, u których
stwierdzono prawidłową LVEF. W artykule podkreślono również, że głównym celem postępowania
u starszych pacjentów z ACS jest minimalizacja ryzyka wieńcowego oraz zwiększenie korzyści terapeutycznych – w indywidualnym kontekście klinicznym, psychospołecznym i rodzinnym danego pacjenta.
(Probl Med Rodz 2012;3(39):44–48)
Introduction
Coronary heart disease (CHD) is the leading
cause of death all over the world, with higher rates
CORRESPONDENCE ADDRESS:
of mortality among women than men1. Elderly
dr med. Katarzyna Anna Rygiel
women with acute coronary syndrome (ACS)
Katedra i Zakład Medycyny
Rodzinnej
Śląski Uniwersytet Medyczny
current evidence indicates that women seek car-
ul. 3 Maja 13/15
41-800 Zabrze
[email protected]
RECEIVED: 14.01.2012
ACCEPTED: 03.04.2012
44
have particularly high cardiovascular risk 2. Also,
diac care less frequently, and are less likely to be
promptly and properly diagnosed and treated,
comparing to men3.
Recently, a lot of reports, related to the practical
use of invasive procedures and pharmacological
therapies, have revealed a lower use of these treatments, among elderly patients (especially women),
including the ones, who could have a real chance
to benefit. This might be in part due to scarcity of
research data on the details of care in geriatric population that is often excluded from clinical studies3. Thus, future trials should enroll the elderly in
proper proportion to their representation in the
general population.
In the context of age-related changes in physiology and greater number of comorbid diseases, or
previous cardiac procedures, treatment risks of the
elderly patients with acute coronary syndromes
PROBLEMY MEDYCYNY RODZINNEJ, SEPTEMBER 2012, VOL. XIV, No. 3
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(ACS) may often overshadow benefits, which are closely
related to the patient-oriented management goals. These topics definitely merit further exploring, via modern research,
in order to bridge many of the existing gaps in coronary care
of the older population.
In the initial presentation and treatment of ACS (including ST-segment elevation myocardial infarction – STEMI
and non-ST-segment elevation myocardial infarction – nonSTEMI) among the elderly patients it is crucial to consider
the role of comorbidities and concomitant medications,
as well as the patient’s needs, expectations, psycho-social
functional level, ethical issues, comfort level, and availability of care. Family and primary care physicians are usually
involved in some aspects of coordination of these complex
management issues.
Physiological differences contributing to
undesirable coronary outcomes in elderly
patients
Studies have shown that morbidity and mortality rates in
patients with myocardial infarction increase with age4,5. For
instance, in the GUSTO-I trial, the 30-day mortality rate
increased 10-fold, from 3.0% among patients younger than
65 years to 30.3% among the ones older than 85 years4. The
age-related lethal complications can be explained by some
physiological changes in heart and blood vessels such as:
•ventricular hypertrophy and remodeling,
•decreased vascular compliance6.
The most serious, age-related cardiovascular complications include:
•heart failure and pulmonary edema – that occur in over
50% of patients older than 75 years, and in over 65% of
patients older than 85 years7,
•cardiogenic shock, manifested by hypotension and hypoperfusion – that occurs in more than 10% of patients
older than 75 years, and is usually secondary to ventricular or papillary muscle rupture or to ventricular
dysfunction8,9.
In addition, myocardial edema and hemorrhage can often
be found on autopsy of the elderly patients, who received
fibrinolytic therapy10. The proportion of patients eligible
for reperfusion decreases with advanced age. Also, elderly
STEMI patients are still less likely to receive reperfusion
(percutaneous coronary intervention – PCI or fibrinolytic
therapy) even if they are eligible. Moreover, many elderly
present with atypical symptoms, previous abnormalities
on ECGs, or comorbidities that may obscure their clinical
PROBLEMY MEDYCYNY RODZINNEJ, SEPTEMBER 2012, VOL. XIV, No. 3
picture, making their treatment more difficult. In this way,
the elderly have a higher likelihood of death after STEMI,
which can be attributed to diastolic or systolic dysfunction,
causing heart failure.
Benefits of PCI versus fibrinolytic therapy
in the elderly population
Based on randomized trials, meta-analyses, and observational studies, risk-benefit ratio favors PCI over fibrinolytic
therapy in the elderly11,12. Although, more data are needed
in patients above 80 years of age, the following findings have
been reported:
•the main benefit from PCI is a reduction in reinfarction
and need for target-vessel revascularization, as well as
mortality reduction,
•adjusting the dose of adjunctive antithrombin agents
with fibrinolytic therapy improves outcome,
•availability and time to reperfusion are key determinants
of myocardial salvage and clinical benefits, regardless of
the applied strategy,
•PCI can be applied without ST-segment elevation or
ongoing chest pain and is preferable in the setting of
shock or high TIMI risk scores.
According to the GRACE registry, patients above 70 years
of age, who underwent PCI versus fibrinolytic therapy had
less reinfarction and death11. Similarly, based on the Cooperative Cardiovascular Project database, among patients
above 65 years of age, PCI was associated with modest
short- or long-term mortality benefits compared with fibrinolytic therapy12.
The timing and availability of PCI often involve emergency transfers to a PCI-capable cardiac care facility, and
this transfer should be considered for the elderly patients:
•at high risk, who present with cardiogenic shock or arrive
more than 3 hours from their symptom onset,
•with contraindications to fibrinolytic therapy, particularly if the “door to balloon” time is less than 90 minutes.
Unfortunately, the mortality rate for STEMI patients
with cardiogenic shock is still high regardless of reperfusion methods13.
Elderly women with a high left ventricular
ejection fraction (LVEF)
Depressed left ventricular function, complicating an ACS,
can independently predicts poor outcome14. Based on previous research, it was reported that the mortality rates were
highest among patients with the low ejection fraction (EF).
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However, according to a recent study, it was found that the
elderly women with a high EF had a higher mortality rate
than the ones, who had a normal EF15.
In general, elderly women with an EF >55% are considered
to have normal systolic function. However, despite having
a normal systolic function, they more often suffer from the
diastolic dysfunction, compared with elderly men16. This can
be due to aging process, often associated with arterial hypertension, myocardial ischemia or infarction, as contributors
to diastolic failure17.
It was reported that the patients with diastolic dysfunction, and without CHD had a relatively good prognosis18.
However, in elderly women with an ACS, who had a high left
ventricular ejection fraction (LVEF) (>65%), there was an
association with higher rates of sudden cardiac death (SCD).
This correlation was higher comparing to those older female
patients, whose LVEF was considered to be in the normal
range. This phenomenon may be related to the fact that after
ACS (e.g.: acute myocardial infarction – AMI), ventricular
function depends on multiple factors, including:
•infarct size,
•location,
•left ventricular contractility at the infracted area19.
According to evidence from clinical trials, the use of intracardiac defibrillators for the prevention of SCD and sustained ventricular tachycardia among patients with severely
depressed LVEF (e.g.: post AMI, with EF <35%), has been
recommended19. However, some recent reports suggest that
a severely depressed left ventricular function might not be
present in many patients, who suffered from sudden death.
In particular, a large, population-based study has revealed
that a majority of sudden cardiac death patients did not have
the severely diminished left ventricular function20. Moreover, in a community-based study, researchers have found
that only 19% of SCD victims had diminished their LVEF,
defined as <30%21.
Elderly women with hypertrophic hearts and a high LVEF
may be particularly susceptible to oxygen supply-mediated
myocardial ischemia. It appears that there is an association
between ACS/AMI and SCD, due to ischemia-mediated
ventricular tachycardia or ventricular fibrillation22. This
evidence could impact the physician’s decision making,
related to the diagnostic work-up, which can better identify patients at risk for SCD after ACS (e.g.: electrophysiology study). However, the implication of these results, with
regard to the practical patient management merits further
exploration in research trials.
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Adjunctive pharmacotherapy in the elderly
patients
The following short- and long-term benefits of adjunctive pharmacotherapy have been found among the elderly
patients:
•ß-blockers have greater benefits in the elderly patients
for the prevention of subsequent MI and death than in
younger groups. However, given the potential hypotensive and bradycardic adverse effects of intravenous
ß-blockers, their use in STEMI with hemodynamic compromise is contraindicated.
•ACE (angiotensin converting enzyme) inhibitors and
angiotensin receptor blockers (ARB) are beneficial in
the elderly, particularly in heart failure or reduced left
ventricular function.
•Statins have benefits in the elderly for the prevention of
subsequent MI.
•Nitrates may be useful in the elderly, because of their
effects on preload, afterload, and reducing recurrent
myocardial ischemia22.
Medical ethics and acute cardiac care of the
elderly
Ethical uncertainty in the acute coronary care of the elderly
often arises from the limited evidence base and multiplicity
of patient preferences or other relevant clinical or personal
circumstances23. There is no doubt that the interventions
with questionable benefit or significant risk of harm should
be avoided. Of course, more data regarding risk and benefit
of different interventions among the elderly (above 75 years
of age), and quality-of-life issues are still needed, in order
to allow both elderly patients and their families to make
informed decisions about their
•acute, hospital-based treatment,
•follow-up rehabilitation,
•post-discharge home care.
These additional information would facilitate the care rendered by cardiology specialists, in collaboration with family
and primary care physicians, to growing elderly population
with ACS. Some patients may not desire certain aggressive
treatment methods or “heroic efforts”, especially in face of
overall poor prognosis. At this point, their wishes should
be respected. As always, a sound clinical judgment is very
important in achieving the most optimal outcomes among
elderly population in a cost-effective and patient-centered
way. Also, more data on quality-of-life outcomes are needed.
It appears that the elderly individuals should:
PROBLEMY MEDYCYNY RODZINNEJ, SEPTEMBER 2012, VOL. XIV, No. 3
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•engage in conversations with loved ones about health
preferences well in advance of their potential, and sometimes predictable healthcare crisis,
•be encouraged to prepare their healthcare wishes and
advanced directives (oral or written such as a “living
will”), as paramount documentation, for guiding and
ensuring autonomous care.
On the other hand, discussing risk-benefit ratio or patient’s
preferences in the acute care setting can often be challenging or hectic.
Summary
The main challenges in management of ACS in the elderly
population are related to patient atypical presentations,
advanced comorbidities, delayed arrival to specialistic cardiology centers, and limited research data, since geriatric
patients are often excluded from clinical trials. Even though
the eligibility for reperfusion declines with age, the elderly
patients are less likely to receive reperfusion, even if they
meet those criteria. There is a general agreement that the
benefit associated with reperfusion is substantial in patients
younger than 85 years, and a choice of fibrinolytics vs. PCI
is determined by the time from presentation, comorbidities,
or presence of cardiogenic shock (that may be indication
for PCI). The safety and efficacy of reperfusion (especially
fibrinolytic therapy) among elderly patients above 85 years
of age remains questionable and requires further research,
including information from ACS registries and clinical trials. In the elderly with ACS, the most important care topics
are related to the:
•benefit-risk ratio of invasive treatments and newer medications in context of physiological changes in advanced
age and comorbidities,
•selection criteria and doses of various medications or
adjunctive treatments,
•management of complications and interactions of medications,
•quality-of-life outcomes,
•patients’ choices, needs or wishes with relation to their
level of psycho-physical functioning.
In elderly women with an ACS, poor left ventricular systolic
function has traditionally been associated with the worst outcomes. However, according to a recent study, some elderly
women with preserved left ventricular function, those who
had a high EF, experienced a 2-fold increased risk of mortality, cardiac arrest or ventricular fibrillation, comparing
to those, who had a normal left ventricular ejection fraction
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(LVEF). Of course, these findings need to be explored and
confirmed in further clinical studies. In the meantime, local
community registries are helpful in assessment of risks and
benefits of acute care in the elderly patients, in real-world
hospital practice.
There is no doubt that the efficient communication between
cardiologists, ambulance and hospital personnel, and family or primary care physicians, who are familiar with many
aspects of the patient’s condition, is essential. In addition,
some standard procedures, designed to reduce pre-hospital
delays in detection, proper diagnosis, transfer, and treatment of ACS in the elderly need to be improved.
Also, an important message to family and primary care
physicians is that a common “one-size-fits-all” approach
to the management of elderly patients is not appropriate in
this heterogeneous population. Moreover, it is not acceptable due to many ethical reasons or dilemmas. Also, some
potential treatment outcomes, related to the quality of life,
physical, mental and emotional status, as well as ability to
function independently need to be considered individually,
based on long-term doctor-patient relationships in the primary care setting. After stabilization of the patient’s condition, during his/her hospital stay, and then post-discharge,
the following mnemonic – ABCDE – might be helpful, as
follow-up strategy:
A = Aspirin, ACEI, ARB, and antianginals
B = Beta-blockers and BP control
C = Cholesterol level and cigarettes smoking cessation
D = Diet and diabetes mellitus care
E = Education and exercises
List of abbreviations:
ACEI – angiotensin converting enzyme inhibitors;
ACS – acute coronary syndrome;
AMI – acute myocardial infarction;
ARB – angiotensin receptor blockers;
CHD – coronary heart disease;
CHF – chronic heart failure, congestive heart failure;
CVD – cardiovascular disease;
ECG or EKG – electrocardiogram;
EF – ejection fraction;
LVEF – left ventricular ejection fraction;
MI – myocardial infarction;
NSTEMI – non-ST segment elevation myocardial infarc
tion;
PCI – percutaneous coronary intervention;
SCD – sudden cardiac death;
STEMI – ST-elevation myocardial infarction;
UA – unstable angina.
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