AHA Releases Scientific Statement on Acute Coronary Syndromes in Older Patients

Abdulla Damluji, MD, PhD

The American Heart Association (AHA) has released a scientific statement offering clinicians with updated age-specific guidance related to diagnosis and management of acute coronary syndromes (ACS) in older patients.

With the proportion of older adults in the US continuing to increase, the AHA’s latest scientific statement provides timely and relevant information centered around diagnosis and management of ACS in people aged 75 years or older.

“Older patients have more pronounced anatomical changes and more severe functional impairment, and they are more likely to have additional health conditions not related to heart disease,” said Abdulla A. Damluji, MD, PhD, chair of the scientific statement writing committee, director of the Inova Center of Outcomes Research, and an associate professor of medicine at Johns Hopkins School of Medicine in Baltimore, in a statement from the AHA. “These include frailty, other chronic disorders (treated with multiple medications), physical dysfunction, cognitive decline and/or urinary incontinence – and these are not regularly studied in the context of ACS.”

Published on December 12, the statement was prepared by a volunteer writing committee composed of Damluji and 9 colleagues on behalf of several AHA councils, including the Cardiovascular Diseases in Older Populations Committee of the Council on Clinical Cardiology, the Council on Cardiovascular and Stroke Nursing, the Council on Cardiovascular Radiology and Intervention, and the Council on Lifestyle and Cardiometabolic Health. At 31 pages in length and citing 197 references, the authors outlined the specific aims of their statement within the abstract of the document. These specific aims were listed as reviewing age-related physiological changes that predispose to acute coronary syndrome and management complexity, describing the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes, and recommending age-appropriate and guideline-concordant revascularization and ACS management strategies.

With this in mind, the statement has 9 sections dedicated to topics ranging from cardiovascular aging to GDMT for ACS and transitions, rehabilitation, and follow-up. Within the 9 sections are one or more subsections, considerations for clinical practice, and key points as well as several tables and graphs depicting best practices, trial evidence, physiologic changes impacting pharmacokinetics and pharmacodynamics of medications in older adults.

“Geriatric syndromes and the complexities of their care may undermine the effectiveness of treatments for ACS, as well as the resiliency of older adults to survive and recover,” Damluji added. “A detailed review of all medications – including supplements and over-the-counter medicines – is essential, ideally in consultation with a pharmacist who has geriatric expertise.”

Within the aforementioned statement from the AHA, the organization calls specific attention to a group of clinical considerations in the document related to normal aging and age-related changes in the heart and blood vessels. Some of these considerations are highlighted below:

• ACS is more likely to occur without chest pain in older adults, presenting with symptoms such as shortness of breath, fainting or sudden confusion.
• Troponin levels may already be higher in older people, especially those with kidney disease and a stiffened heart muscle. Evaluating patterns of the rise and fall of troponin levels may be more appropriate when using it to diagnose heart attacks in older adults.
• Age-related changes in metabolism, weight and muscle mass may necessitate different choices in anti-clotting medications to lower bleeding risk.
• As kidney function declines, the risk of kidney injury increases, particularly when contrast agents are used in imaging tests and procedures guided by imaging.
• Although many clinicians avoid cardiac rehabilitation for patients who are frail, they often benefit the most.

A portion of the statement is also dedicated to patient preferences and life expectancy. Within this section, the authors provide perspective on goalsetting in the care of older patients and those palliative care touching upon quality of life metrics and discussions around potential do-not-resuscitate orders.

This statement, “Management of Acute Coronary Syndrome in the Older Adult Population,” was published in Circulation.