European Heart Journal Advance Access originally published online on April 23, 2008
European Heart Journal 2008 29(10):1213-1214; doi:10.1093/eurheartj/ehn184
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Acute coronary syndrome in the elderly
Department of Cardiology, University of Antwerp-University Hospital Antwerp, Wilrijkstraat 10, B-2650, Edegem, Belgium
* Corresponding author. Tel: +32 3 8213525, Fax: +32 3 8302305, Email: christiaan.vrints{at}ua.ac.be
This editorial refers to ‘Management and 6-month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: The Global Registry of Acute Coronary Events’
, by G. Devlin et al., on page 1275
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
doi:10.1093/eurheartj/ehn124 
In the well developed countries of the world, ischaemic heart disease is the prevailing cause of death among patients aged >65 years.1 In Europe, more than in other countries in the world, we will witness during the next few decades a dramatic surge of patients with ischaemic heart disease due to the progressive ageing of our population.2 Because of the continuing increase in life expectancy, many of these patients with ischaemic heart disease will be aged >75 years. Similar to women, elderly patients are under-represented in clinical trials. If not excluded by age, many elderly patients are excluded from clinical trials because of existing co-morbidities or other serious systemic illnesses. We therefore risk in the future being confronted with scores of elderly people with ischaemic heart disease without having enough scientific evidence for guidance on how to treat them. Any new evidence on the therapy of ischaemic heart disease in elderly patients is therefore more then welcome. If randomized clinical trials organized by the industry do not provide enough information, then continuing registries of clinical practice based on a voluntary contribution by clinicians may offer help.
Acute coronary syndromes in the elderly risk being undertreated both medically and by coronary interventions because of fear of bleeding and other complications.3 On the other hand, elderly patients represent a very high-risk group that may benefit the most from potent antithrombotic regimens and coronary interventions that have been shown to improve clinical outcome significantly in younger patients. Although these therapies are expensive, cost considerations should not be used to hold back invasive management of acute coronary syndromes in the elderly since an invasive approach has already been shown to be more cost-effective than optimized medical therapy in elderly patients with chronic stable angina.4
Devlin et al. report an analysis on the in-hospital events and 6 months outcomes in elderly and very elderly patients with high risk non-ST-elevation acute coronary syndromes (NSTE-ACS) who were included in the GRACE registry.5 In this registry, an evidence-based approach including angiography and revascularization was progressively less frequently used in elderly and very elderly patients in spite of an increasing GRACE risk score. However, compared with medical treatment, revascularization in both elderly and very elderly patients resulted in very marked reduction of mortality and reinfarction rate similar to that observed in patients of a younger age. As in previous reports, an invasive strategy was associated with an increased incidence of major bleeding complications mainly in the very elderly. The stroke rate, however, remained unchanged.
Although a registry does not provide the same scientific proof as a randomized clinical trial, the present analysis of the GRACE registry clearly also demonstrates the benefits of an invasive management of high risk NSTE-ACS in elderly and very elderly patients. The GRACE registry also demonstrates, however, an important treatment paradox: the more elderly and the more high risk the patient, the less frequently coronary angiography and revascularization are used. This treatment paradox, probably based on a generalized fear not to harm elderly patients by performing invasive interventions, seems unjustified: as in younger patients we can obtain a very significant reduction of 6-month mortality and reinfarction rate with an invasive management of high risk NSTE-ACS in both elderly and very elderly patients. Although recent trials have re-emphasized the value of medical treatment of NSTE-ACS,6,7 we should therefore also apply with ‘courage’ an invasive management approach in elderly patients with high-risk NSTE-ACS.
One element contributing to the reluctance to perform coronary angiography in elderly patients with high-risk NSTE-ACS is the fear of finding complex multivessel disease that would necessitate coronary bypass surgery which is more hazardous with advancing age. However, in the present analysis of the GRACE study, the majority (79%) of the elderly patients were treated with percutaneous coronary intervention (PCI). Fear of the risk of being confronted with the need for coronary bypass surgery is therefore not a good reason to deny elderly patients with high-risk NSTE-ACS the possible benefits of an invasive management. Moreover, even if multivessel disease is found, then this does not obviate the possibility of performing PCI only of the vessel which is to blame for the condition.
It is unclear from the present analysis on which basis patients were selected for an invasive rather than for a conservative management. Further analyses and studies are needed to determine which subsets of elderly patients benefit most from an invasive approach and when to perform a complete surgical revascularization rather than a selective approach with PCI only of the ‘culprit’ vessel.
The analysis of the GRACE registry by Devlin et al.5 also demonstrates the value of continuing registries of medical practice. They are helpful not only by monitoring the implementation of new guidelines but also by providing information on specific patient groups that frequently are under-represented in clinical trials such as elderly and female patients. Although registries have many limitations inherent to their non-randomized approach, incomplete data structure, and possible selection biases, they should be maintained since they offer information on real-life clinical practice that may lead to new approaches and hypotheses that should be verified by randomized trials. Although a lot of information has been gained on the management of acute coronary syndromes, there are still gaps in our knowledge, as shown by this analysis of the GRACE registry.5 Therefore, registries on acute coronary syndromes such as GRACE and the EuroHeart survey on acute coronary syndromes should be continued. Because of these considerations, the ESC working group of Acute Cardiac Care already has decided to continue its acute coronary syndrome registry on a permanent basis.
Conflict of interest: none declared.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
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Related articles in EHJ:
- Management and 6-month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: The Global Registry of Acute Coronary Events
- Gerard Devlin, Joel M. Gore, John Elliott, Namal Wijesinghe, Kim A. Eagle, Álvaro Avezum, Wei Huang, David Brieger, and for the GRACE Investigators
EHJ 2008 29: 1275-1282.[Abstract] [FREE Full Text]
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