Highlights of the statement:
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A new scientific statement from the American Heart Association provides updated information on how aging influences the diagnosis and treatment of heart attacks in people age 75 and older.
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Changes in the cardiovascular system associated with normal aging and non-heart-related medical conditions that become more common with age must be considered when planning heart attack treatment and monitoring.
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Proper care of the elderly is becoming increasingly important as the proportion of older people in the population continues to increase.
Embargoed until 4 a.m..meter. CT / 5 am Eastern Time, Monday, December 12, 2022
(NewMediaWire) – December 12, 2022 – DALLAS For people 75 years and older, age-related changes in general health and in the heart and blood vessels require consideration and likely modifications in how attacks are treated and heart disease, according to a new American Heart Association Scientific Statement published today in the Association’s flagship peer-reviewed journal Circulation.
The new statement, “Management of Acute Coronary Syndrome (ACS) in the Older Adult Population,” highlights recent evidence to help clinicians provide better care for patients older than 75 years. According to the statement, 30-40% of people hospitalized with ACS are 75 or older. DHW includes heart attack Y unstable angina (chest pain related to the heart).
The statement is an update of a American Heart Association 2007 Statement on the treatment of heart attacks in the elderly.
Clinical practice guidelines are based on clinical trial research. “However, older adults are often excluded from clinical trials because their healthcare needs are more complex compared to younger patients,” said Abdulla A. Damluji, MD, Ph.D., FAHA, president of the scientific statement writing committee, director of the Inova Center for Outcomes Research in Fairfax, Virginia, and associate professor of medicine at the Johns Hopkins School of Medicine in Baltimore.
“Older patients have more pronounced anatomical changes and more severe functional impairment, and are more likely to have additional health problems unrelated to heart disease,” Damluji said. “These include frailty, other chronic disorders (treated with multiple medications), physical dysfunction, cognitive impairment, and/or urinary incontinence, and these are not regularly studied in the context of ACS.”
Normal aging and age-related changes in the heart and blood vessels
Cardiovascular changes that occur with normal aging make ACS more likely and can make diagnosis and treatment more complex: large arteries become stiffer; the heart muscle often works harder but pumps less efficiently; blood vessels are less flexible and less able to respond to changes in the heart’s oxygen needs; and there is an increased tendency to form blood clots. Sensory impairment due to aging can also alter hearing, vision, and pain sensations. Kidney function also declines with age, with more than a third of people over the age of 65 having chronic kidney disease. These changes must be taken into account when diagnosing and treating ACS in older adults.
These considerations include:
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ACS without chest pain is more likely to occur in older adults, who present with symptoms such as shortness of breath, fainting, or sudden confusion.
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Measuring levels of the enzyme troponin in the blood is a standard test for diagnosing a heart attack in younger people. However, troponin levels may already be higher in older people, especially those with kidney disease and stiff heart muscle. Assessment of patterns of rising and falling troponin levels may be more appropriate when used to diagnose heart attacks in older adults.
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Age-related changes in metabolism, weight, and muscle mass may require different anticoagulant drug options to reduce the risk of bleeding.
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As kidney function declines, the risk of kidney injury increases, particularly when contrast agents are used in imaging tests and imaging-guided procedures.
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Although many physicians avoid cardiac rehab for frail patients, they often benefit the most.
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Ensuring the continuation of medications and other therapies when people are transferred from the hospital to an outpatient facility is particularly important in older adults who are vulnerable to frailty, deterioration, and complications during these transitions.
Multiple medical conditions and medications
As people age, they are often diagnosed with health problems that may worsen with ACS or may complicate existing ACS. As these chronic conditions are treated, the number of medications prescribed may lead to unwanted interactions, or medications that treat one condition may worsen another.
“Geriatric syndromes and the complexities of their care can undermine the efficacy of ACS treatments, as well as the resilience of older adults to survive and recover,” Damluji said. “A detailed review of all medications, including supplements and over-the-counter medications, is essential, ideally in consultation with a pharmacist who has experience in geriatrics.”
An individualized, patient-centered approach to ACS care is best for older adults, considering coexisting conditions and the need for input from multiple specialists. Ideally, multidisciplinary teams caring for older adults with ACS include cardiologists, surgeons, geriatricians, primary care physicians, nutritionists, pharmacists, cardiac rehabilitation professionals, social workers, nurses, and family members.
Additionally, people with cognitive difficulties and limited mobility may benefit from a simplified medication schedule, with fewer doses per day and 90-day supplies of medication, so fewer refills are needed. Monitoring of symptom burden, functional status, and quality of life during post-discharge follow-up are important to give an idea of how the patient is progressing in relation to their goals of care and gauge potential for improvement.
Patient preferences and life expectancy
Older adults differ widely in their independence, physical or cognitive limitations, life expectancy, and goals for the future. The goals of care for older people with ACS must go beyond clinical outcomes (such as bleeding, stroke, another heart attack, or the need for repeat procedures to reopen arteries). Goals centered on quality of life, ability to live independently, and/or return to previous lifestyle or living environment are important to consider when planning care for older adults with SCA. Also, Do Not Resuscitate (DNR) orders should be discussed before any surgery or procedure.
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Although the risks are greater, bypass surgery or procedures to reopen a blocked artery are beneficial in selecting older adults with ACS.
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If invasive treatment is chosen, a DNR order may have to be suspended for the duration of the procedure.
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If invasive treatment is not chosen, palliative care can help control symptoms, improve quality of life, and provide psychosocial support.
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Important metrics for quality care include measurable goals such as days spent at home and relief from pain and discomfort.
This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association Committee on Cardiovascular Disease in Elderly Populations of the Board of Clinical Cardiology; the Cardiovascular and Stroke Nursing Council; the Council of Radiology and Cardiovascular Intervention; and the Council for Lifestyle and Cardiometabolic Health. Scientific statements from the American Heart Association promote greater awareness of cardiovascular disease and stroke and help facilitate informed health care decisions. Scientific statements describe what is currently known about a topic and what areas need further research. While scientific statements inform guideline development, they do not make treatment recommendations. The American Heart Association guidelines provide the Association’s official clinical practice recommendations.
Coauthors are Vice President Daniel E. Forman, MD, FAHA; Tracy Y. Wang, MD, MHS, M.Sc., FAHA; Joanna Chikwe, MD, FAHA; Vijay Kunadian, MBBS, MD; Michael W. Rico, MD; Bessie A Young, MD, MPH; Robert L. Page II, Pharm.D., MSPH, FAHA; Holli A. DeVon, Ph.D., RN, FAHA; and Karen P. Alexander, MD, FAHA. Author statements are listed in the manuscript.
The Association receives funding mainly from individuals. Foundations and corporations (including pharmaceuticals, device manufacturers, and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing scientific content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers, and general financial information from the Association are available here.
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About the American Heart Association
The American Heart Association is a relentless force for a world of longer, healthier lives. We are dedicated to ensuring equitable health in all communities. Through collaboration with numerous organizations and with the support of millions of volunteers, we fund innovative research, advocate for public health, and share life-saving resources. The Dallas-based organization has been a leading source of health information for nearly a century. Connect with us at heart.org, Facebook, Twitter or by calling 1-800-AHA-USA1.
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