Skip to main content
Clinical Cardiology logoLink to Clinical Cardiology
. 2009 Nov 24;32(11):608–613. doi: 10.1002/clc.20623

Acute Coronary Syndrome in the Elderly

Madhan Shanmugasundaram 1,, Joseph S Alpert 2
PMCID: PMC6653374  PMID: 19938045

Abstract

The spectrum of acute coronary syndrome (ACS) including unstable angina, non–ST‐elevation myocardial infarction and ST‐elevation myocardial infarction accounts for increasing numbers of deaths among persons age ≥ 65 years in the US. This is important given demographic changes involving falling birth rates and increasing life expectancy. Elderly patients are likely to benefit the most from treatment of ACS, even though community practice still demonstrates less use of cardial medications as an early‐invasive approach among this population. Copyright © 2009 Wiley Periodicals, Inc.

Full Text

The Full Text of this article is available as a PDF (173.5 KB).

References

  • 1. Kochanek KD, Smith BL. Deaths: preliminary data for 2002. Natl Vital Stat Rep 2004; 52(13): 1–47. [PubMed] [Google Scholar]
  • 2. Yancik R. Cancer burden in the aged: An epidemiologic and demographic overview. Cancer 1997; 80(7): 1273–1283. [PubMed] [Google Scholar]
  • 3. Yan AT, Yan RT, Tan M, et al. Management patterns in relation to risk stratification among patients with non‐ST elevation acute coronary syndromes. Arch Intern Med 2007; 167(10): 1009–1016. [DOI] [PubMed] [Google Scholar]
  • 4. McAlister FA, Oreopoulos A, Norris CM, et al. Exploring the treatment‐risk paradox in coronary disease. Arch Intern Med 2007; 167(10): 1019–1025. [DOI] [PubMed] [Google Scholar]
  • 5. Yan AT, Yan RT, Huynh T, et al. Understanding physicians' risk stratification of acute coronary syndromes: insights from the Canadian ACS 2 Registry. Arch Intern Med 2009; 169(4): 372–378. [DOI] [PubMed] [Google Scholar]
  • 6. 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: developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST‐Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation 2008; 117(2): 296–329. [DOI] [PubMed] [Google Scholar]
  • 7. 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(7): e1–e157. [DOI] [PubMed] [Google Scholar]
  • 8. Collaborative overview of randomised trials of antiplatelet therapy—I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. BMJ 1994; 308(6921): 81–106. [PMC free article] [PubMed] [Google Scholar]
  • 9. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST‐segment elevation. N Engl J Med 2001; 345(7): 494–502. [DOI] [PubMed] [Google Scholar]
  • 10. Mehta SR, Yusuf S, Peters RJ, et al. Effects of pretreatment with clopidogrel and aspirin followed by long‐term therapy in patients undergoing percutaneous coronary intervention: the PCI‐CURE study. Lancet 2001; 358(9281): 527–533. [DOI] [PubMed] [Google Scholar]
  • 11. Chen ZM, Jiang LX, Chen YP, et al. Addition of clopidogrel to aspirin in 45 852 patients with acute myocardial infarction: randomised placebo‐controlled trial. Lancet 2005; 366(9497): 1607–1621. [DOI] [PubMed] [Google Scholar]
  • 12. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med 1998; 339(7): 436–443. [DOI] [PubMed] [Google Scholar]
  • 13. Sadeghi HM, Grines CL, Chandra HR, et al. Percutaneous coronary interventions in octogenarians. glycoprotein IIb/IIIa receptor inhibitors' safety profile. J Am Coll Cardiol 2003; 42(3): 428–432. [DOI] [PubMed] [Google Scholar]
  • 14.ESPRIT Investigators. Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy. Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo‐controlled trial. Lancet 2000; 356(9247): 2037–2044. [DOI] [PubMed] [Google Scholar]
  • 15. Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta‐analysis of all major randomised clinical trials. Lancet 2002; 359(9302): 189–198. [DOI] [PubMed] [Google Scholar]
  • 16. Campbell NR, Hull RD, Brant R, Hogan DB, Pineo GF, Raskob GE. Aging and heparin‐related bleeding. Arch Intern Med 1996; 156(8): 857–860. [PubMed] [Google Scholar]
  • 17. Cohen M, Antman EM, Gurfinkel EP, Radley D; ESSENCE (Efficacy and Safety of Subcutaneous Enoxaparin in Non‐Q‐wave Coronary Events) and TIMI (Thrombolysis in Myocardial Infarction) 11B Investigators. Enoxaparin in unstable angina/non‐ST‐segment elevation myocardial infarction: treatment benefits in prespecified subgroups. J Thromb Thrombolysis 2001; 12(3): 199–206. [DOI] [PubMed] [Google Scholar]
  • 18. Cohen M, Demers C, Gurfinkel EP, et al. A comparison of low‐molecular‐weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non‐Q‐Wave Coronary Events Study Group. N Engl J Med 1997; 337(7): 447–452. [DOI] [PubMed] [Google Scholar]
  • 19. Invasive compared with non‐invasive treatment in unstable coronary‐artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet 1999; 354(9180): 708–715. [PubMed] [Google Scholar]
  • 20. Antman EM, McCabe CH, Gurfinkel EP, et al. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non‐Q‐wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Circulation 1999; 100(15): 1593–1601. [DOI] [PubMed] [Google Scholar]
  • 21. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. The Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) Angioplasty Substudy Investigators. N Engl J Med 1997; 336(23): 1621–1628. [DOI] [PubMed] [Google Scholar]
  • 22. Lincoff AM, Bittl JA, Harrington RA, et al. Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention: REPLACE‐2 randomized trial. JAMA 2003; 289(7): 853–863. [DOI] [PubMed] [Google Scholar]
  • 23. Mehta RH, Sadiq I, Goldberg RJ, et al. Effectiveness of primary percutaneous coronary intervention compared with that of thrombolytic therapy in elderly patients with acute myocardial infarction. Am Heart J 2004; 147(2): 253–259. [DOI] [PubMed] [Google Scholar]
  • 24. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 1994; 343(8893): 311–322. [PubMed] [Google Scholar]
  • 25. Stenestrand U, Wallentin L; Register of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS‐HIA). Fibrinolytic therapy in patients 75 years and older with ST‐segment‐elevation myocardial infarction: one‐year follow‐up of a large prospective cohort. Arch Intern Med 2003; 163(8): 965–971. [DOI] [PubMed] [Google Scholar]
  • 26. 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): 370–377. [DOI] [PubMed] [Google Scholar]
  • 27. 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. [DOI] [PubMed] [Google Scholar]
  • 28. Lagerqvist B, Husted S, Kontny F, et al. 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(11): 1902–1914. [DOI] [PubMed] [Google Scholar]
  • 29. Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA. National use and effectiveness of β‐blockers for the treatment of elderly patients after acute myocardial infarction: National Cooperative Cardiovascular Project. JAMA 1998; 280(7): 623–629. [DOI] [PubMed] [Google Scholar]
  • 30.Metoprolol in acute myocardial infarction (MIAMI). A randomised placebo‐controlled international trial. The MIAMI Trial Research Group. Eur Heart J 1985; 6(3): 199–226. [PubMed] [Google Scholar]
  • 31. Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45 852 patients with acute myocardial infarction: randomised placebo‐controlled trial. Lancet 2005; 366(9497): 1622–1632. [DOI] [PubMed] [Google Scholar]
  • 32. GISSI‐3: Effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6‐week mortality and ventricular function after acute myocardial infarction. Gruppo Italiano per lo Studio della Sopravvivenza nell'infarto Miocardico. Lancet 1994; 343(8906): 1115–1122. [PubMed] [Google Scholar]
  • 33. Pfeffer MA, Braunwald E, Moye LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med 1992; 327(10): 669–677. [DOI] [PubMed] [Google Scholar]
  • 34. Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Lancet 1993; 342(8875): 821–828. [PubMed] [Google Scholar]
  • 35. Krumholz HM, Chen YT, Wang Y, Radford MJ. Aspirin and angiotensin‐converting enzyme inhibitors among elderly survivors of hospitalization for an acute myocardial infarction. Arch Intern Med 2001; 161(4): 538–544. [DOI] [PubMed] [Google Scholar]
  • 36. Dickstein K, Kjekshus J; OPTIMAAL Steering Committee of the OPTIMAAL Study Group. Effects of losartan and captopril on mortality and morbidity in high‐risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan. Lancet 2002; 360(9335): 752–760. [DOI] [PubMed] [Google Scholar]
  • 37. Pfeffer MA, McMurray JJ, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 2003; 349(20): 1893–1906. doi:10.1056/NEJMoa032292. [DOI] [PubMed] [Google Scholar]
  • 38. White HD, Aylward PE, Huang Z, et al. Mortality and morbidity remain high despite captopril and/or valsartan therapy in elderly patients with left ventricular systolic dysfunction, heart failure, or both after acute myocardial infarction: results from the Valsartan in Acute Myocardial Infarction Trial (VALIANT). Circulation 2005; 112(22): 3391–3399. [DOI] [PubMed] [Google Scholar]
  • 39. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003; 348(14): 1309–1321. doi:10.1056/NEJMoa030207. [DOI] [PubMed] [Google Scholar]
  • 40. Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease. II. Unstable angina, heart failure, primary prevention with aspirin, and risk factor modification. JAMA 1988; 260(15): 2259–2263. [PubMed] [Google Scholar]
  • 41. Six‐month effects of early treatment with lisinopril and transdermal glyceryl trinitrate singly and together withdrawn six weeks after acute myocardial infarction: the GISSI‐3 trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico. J Am Coll Cardiol 1996; 27(2): 337–344. [PubMed] [Google Scholar]
  • 42. Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004; 350(15): 1495–1504. [DOI] [PubMed] [Google Scholar]
  • 43. de Lemos JA, Blazing MA, Wiviott SD, et al. Early intensive vs a delayed conservative simvastatin strategy in patients with acute coronary syndromes: phase Z of the A to Z trial. JAMA 2004; 292(11): 1307–1316. [DOI] [PubMed] [Google Scholar]
  • 44.Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high‐risk individuals: a randomised placebo‐controlled trial. Lancet 2002; 360(9326): 7–22. [DOI] [PubMed] [Google Scholar]
  • 45. Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002; 360(9346): 1623–1630. [DOI] [PubMed] [Google Scholar]

Articles from Clinical Cardiology are provided here courtesy of Wiley

RESOURCES