Management of Acute Coronary Syndromes in Older People

Roy L. Soiza

Disclosures

Age Ageing. 2018;47(1):2-3. 

The history of the standard management of acute coronary syndrome in older people, particularly unstable angina (UA) and non-ST segment elevation MI (NSTEMI), is littered with examples of age discrimination and alleged ageism. A Department of Health commissioned report by the Centre for Policy in Ageing into ageism in NHS hospitals concluded that 'there is clear and widespread evidence of age discrimination in the hospital based investigation and treatment of heart disease and in the instigation of secondary prevention regimes following treatment'.[1] The report also commented that the differences were so marked that they were unlikely to be accounted for by co-morbidity or frailty. Although the days when Coronary Care Units unashamedly excluded adults aged 65 years or over had all but gone by the year 2000,[2] some controversies remain. Guidelines recommend an interventionist approach in those at high risk of further cardiac events or death. Since increasing age is a major risk factor for poor outcome and the prevalence of most other major risk factors also increases with age, older people with UA and NSTEMI usually fall into this high risk group. Despite this, studies continue to show older people are less likely to receive these evidence-based interventions,[3] probably because of the increased risk of iatrogenic injury or concern over futility. Other perennial challenges include the greater frequency of atypical presentations in older people[4] and the poorer predictive accuracy of commonly used risk stratification tools.[5]

The After Eighty Study randomised 457 consenting patients aged over 80 years with UA or NSTEMI to receive either an invasive or conservative strategy.[6] They did not include clinically unstable patients (e.g. those with ongoing episodes of chest pain) as guidelines recommend invasive approaches where possible. The primary outcome analysis showed that the intention to treat with an invasive approach was superior to conservative for the composite end-point of major acute cardiovascular events or death after a median follow-up of 1.53 years (40.6% vs. 61.4%, hazard ratio (HR) 0.53 (0.35–0.76, P = 0.0001)). The invasive group had significantly lower rates of myocardial infarction (HR 0.52, P = 0.001) and need for subsequent urgent revascularisation (HR 0.19, P = 0.001), though lower rates of stroke (HR 0.60, P = 0.26) and death from any cause (HR 0.89, P = 0.53) did not reach statistical significance. There was no significant difference in bleeding events at the end of follow-up. In a pre-specified secondary outcome analysis published in this edition of Age & Ageing, Tegn et al. report that there was no significant difference in quality of life at one year between the two approaches.[7]

This study is of importance to those who look after older people with UA/NSTEMI as it is the first adequately powered trial designed specifically for people aged 80 or over. Although an invasive strategy is known to be superior to conservative management overall,[8] it was unclear if this remained true for the oldest patients as previous studies were underpowered due to the under-representation (and sometimes exclusion) of older adults.[9] Moreover, the authors should be commended for looking at quality of life, an outcome of arguably greater relevance to the study participants than their primary composite outcome. The non-inferiority of the intervention arm relative to the conservative one combined with the previously published improvements in cardiovascular outcomes suggest that an intention to treat invasively should be the norm for those aged 80 or over presenting with UA/NSTEMI who are stable on presentation or after initial medical management.

There are some important considerations in interpreting this result and recommendation. The study did not include adults without capacity to provide informed, written consent. There is potential for selection bias as only 11% of all cases of NSTEMI or UA aged over 80 presenting during the study period were recruited. Approximately half the invasive group received only medical optimisation rather than any attempted revascularisation. The greater efficacy of the intervention arm became progressively diluted with increasing age. Improved outcomes in those aged 90 or over remained but did not reach statistical significance, possibly because of low numbers. Nevertheless, this suggests that there would be a point where an invasive strategy is likely to be futile or cardiologists are usually reluctant to intervene based on current evidence. Doubts therefore remain whether frailer older patients benefit from invasive intervention.

Specialists in older people's medicine may intuitively conclude that past and present examples of age discrimination in UA/NSTEMI may reflect ageist attitudes amongst cardiologists or other non-geriatricians. However, a study in London of 6,093 referral practices using hypothetical cases showed geriatricians were much less likely than general practitioners or cardiologists to refer older patients for indicated evidence-based therapies such as angiography or revascularisation.[10] They were also less likely than general practitioners to refer patients with UA to cardiologists. Whether these differences reflect a knowledge or attitudinal deficit among geriatricians or learned behaviour from differences in access to interventions or outcomes in frail older people is unclear. While the need for a person-centred and individually tailored approach is always paramount, the results of the After Eighty Study are another reminder that there is no place for discriminatory clinical practices based on age alone. The current evidence suggests older people with NSTEMI/UA should usually be referred to an interventional cardiologist for consideration of invasive treatment.

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