Francesc Formiga, Albert Ariza-Solé

1Geriatric Medicine Unit, Internal Medicine Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain

2Department of Cardiology, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain

Keywords: Acute coronary syndromes; Management; Prognosis; The elderly

The progressive ageing of the population and the high incidence of acute coronary syndromes (ACS) in the elderly is leading to an important increase in the number of elderly patients admitted for ACS.[1]Nevertheless, the information about the optimal clinical management in this age group is scarce due to the exclusion of older patients from clinical trials.[2]Higher comorbidity and frailty are common in this clinical setting and they are associated with higher rates of complications and consumption of healthcare resources.[3]These are the main reasons for launching this special issue about management of ACS in the elderly, in which several experts in the field address some of the most important questions about how to deal with ACS in patients at older ages.

Firstly, it is important to note that ageing is a heterogeneous process, and the reasons why different patients have different velocities of ageing are poorly understood.During the last decade, the assessment of frailty and other ageing related variables has received a growing interest.[4]Frailty has been consistently associated to a lower adherence to guidelines, a more conservative management and poorer clinical outcomes.[5]Several tools for frailty assessment have been developed during the last years, and some questions regarding the best moment for frailty measurement, which tool to use in each clinical setting and which clinical decisions have to be taken according to frailty measurements remain open. In this issue of the journal,Tonet, et al.[6]perform an extensive review about how and when is important to measure frailty in elderly patients with ACS and which are the main reasons for doing it. We agree with their opinion that scales and timing of assessment can be individualized according to the clinical condition and presentation, the expertise of the team and the final aim.

Also in this issue Vicent, et al.[7]evaluate the complex interaction between gender and frailty in elderly patients with ACS. Women with ACS are usually older than men,they have a higher prevalence of frailty and comorbidities,they are managed conservatively more commonly.[8]The authors remark the need of a multidimensional approach in frail elderly women with ACS and the need to follow clinical recommendations also in this vulnerable group of patients.[7]

Delirium and frailty are two distinct clinical geriatric conditions, that they appear simultaneously in older adults.In fact, delirium is a relatively common complication among elderly patients hospitalized for medical or surgical reasons.[9]However, little information exists about its incidence,predictors and prognostic implications in hospitalized patients with ACS at older ages. In an interesting contribution to this issue, Vives-Borrás, et al.[10]assessed that in 527 octogenarian patients with non-ST-segment elevation ACS the incidence and predictors of delirium and its association clinical outcomes at six months, and they found a low incidence of delirium (7%). Delirium was more common in previous patients with dementia or depression and they are also in the group of previously institutionalized. Patients with delirium had longer hospitalizations and higher incidence of 6-month bleeding and mortality. Importantly, delirium was independently associated with 6-month mortality.One limitation of the study, as stated by the authors, is the fact that delirium was not screened daily, thus potentially leading to a lower incidence of delirium in this real life series of elderly patients with ACS. Given that recommended risk-stratification tools for ACS do not consider specific geriatric factors, analysis of delirium is a potentially useful measure to improve clinical management in elderly patients with ACS.

Clinical, guidelines[11]recommend an early invasive strategy in most cases of non-ST segment elevation ACS(NSTE-ACS). However, these recommendations are based on studies including young patients with a low overall risk.Garcia-Blas, et al.[12]address the role of an invasive strategy during the index admission episode in elderly patients with ACS. Several issues such as the conflicting results of the few randomized clinical trials assessing this topic,[13,14]the highly selected low risk patients included in most of these studies and the lack of information about frailty and comorbidities are discussed in this interesting review. The authors conclude that, until ongoing clinical trials in frail elderly patients become available, a strict conservative strategy should be discouraged in ACS patients at older ages,[13]whereas the use of a routine invasive strategy may reduce the occurrence of myocardial infarction and need for revascularization at follow-up, with no established benefit in terms of mortality. The authors also stressed the importance of ongoing trials based on frailty and comorbidities,[15]in order to optimize clinical management in this poorly studied profile of patients.

Bleeding risk prediction in older patients with ACS is also a major issue to be addressed in this monographic issue.Previous data suggested a lower performance of some bleeding risk scores in patients at older ages and the need for adapting clinical tools for optimizing its performance in the elderly.[16]Rioboo-Leston, et al.[17]performed an interesting review about how to predict bleeding episodes in these patients and how these measures should impact their clinical management. In this sense, type and duration of antiplatelet therapy after an ACS is a continuous matter of debate. This is especially challenging in elderly patients,given their higher risk both for ischemic and bleeding complications, and the lack of specific trials including frail and comorbid patients. Also in this special issue, De Rosa, et al.[18]provide detailed data about available scientific evidence, current gaps in knowledge and ongoing trials regarding this topic. Despite the lack of solid evidence, new strategies such as de-escalating antiplatelet therapy[19]after the acute phase and shorter duration of P2Y12receptors should be a reasonable approach in the group of older patients, especially in those patients at high risk for major bleeding.[20]

In conclusion, the information included in this special issue may contribute to reducing the gaps in evidence about risk stratification and management of elderly patients with ACS. Improving clinical management in these complex patients may lead to important clinical, social and economic consequences.