A new scientific statement from the American Heart Association provides up-to-date information on how aging influences the diagnosis and treatment of heart attacks in people aged 75 and over.
Changes in the cardiovascular system associated with normal aging and non-heart-related medical conditions that become more common with age should be considered when planning treatment and monitoring heart attacks.
Appropriate care for the elderly is increasingly important as the proportion of elderly people in the population continues to rise.
Embargoed until 4 a.m..m. CT / 5 a.m. ET Monday, December 12, 2022
(NewMediaWire) – December 12, 2022 – DALLAS For people aged 75 and over, age-related changes in general health and in the heart and blood vessels require attention and likely changes in the way heart attacks and heart disease are treated, according to a new American Heart Association Scientific Statement published today in the Association’s flagship peer-reviewed journal Traffic.
The new statement, “Management of Acute Coronary Syndrome (ACS) in the Older Adult Population,” highlights recent evidence to help clinicians better care for patients over the age of 75. According to the statement, 30 to 40 percent of people hospitalized with ACS are aged 75 or older. The ACS includes heart attack and unstable angina (chest pain of cardiac origin).
The statement is an update of a 2007 statement from the American Heart Association on the treatment of heart attacks in the elderly.
Clinical practice guidelines are based on clinical trial research. “However, older people are often excluded from clinical trials because their healthcare needs are more complex than those of younger patients,” said Abdulla A. Damluji, MD, Ph.D., FAHA, committee chair. writer, director of the Inova Center for Outcomes Research in Fairfax, Va., and associate professor of medicine at Johns Hopkins School of Medicine in Baltimore.
“Older patients have more pronounced anatomical changes and more severe functional impairment, and they are more likely to have additional health problems unrelated to heart disease,” Damluji said. “These include frailty, other chronic conditions (treated with multiple medications), physical dysfunction, cognitive decline 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 its 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 decline due to aging can also impair hearing, vision, and pain sensations. Kidney function also declines with age, with more than a third of people aged 65 and over having chronic kidney disease. These changes should be considered when diagnosing and treating ACS in the elderly.
These considerations include:
ACS is more likely to occur without chest pain in older people, with symptoms such as shortness of breath, fainting, or sudden confusion.
Measuring levels of the enzyme troponin in the blood is a standard test for diagnosing a heart attack in young people. However, troponin levels may already be higher in older people, especially those with kidney disease and stiff heart muscle. Assessing patterns of rising and falling troponin levels may be more appropriate when used to diagnose heart attacks in the elderly.
Age-related changes in metabolism, weight, and muscle mass may necessitate different blood-thinning drug choices to reduce the risk of bleeding.
As kidney function declines, the risk of kidney injury increases, especially when contrast agents are used in imaging tests and image-guided procedures.
Although many clinicians avoid cardiac rehabilitation for frail patients, they often benefit the most.
It is particularly important to ensure that medications and other therapies are continued when people are transferred from hospital to an outpatient center in older people who are vulnerable to frailty, decline and complications over the course of these transitions.
Several medical conditions and medications
As people age, they are often diagnosed with health conditions that can be made worse by an ACS or complicate an existing ACS. As these chronic conditions are treated, the number of medications prescribed can lead to adverse interactions, or medications that treat one condition can make another condition worse.
“Geriatric syndromes and the complexity of their care can affect the effectiveness of treatments for ACS, 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 expertise in geriatrics.”
An individualized, patient-centered approach to ACS care, given the coexisting conditions and the need for input from multiple specialists, is best for the elderly. Ideally, multidisciplinary teams caring for older adults with ACS include cardiologists, surgeons, geriatricians, primary care clinicians, nutritionists, pharmacists, cardiac rehabilitation professionals, social workers, nurses and family members.
Additionally, people with cognitive difficulties and reduced mobility can benefit from a simplified medication schedule, with fewer doses per day and 90-day drug supplies, so fewer refills are needed. Monitoring symptom burden, functional status, and quality of life during post-discharge follow-up is important to provide insight into patient progress against goals of care and assess potential for improvement .
Patient preferences and life expectancy
Older people differ significantly in their independence, physical or cognitive limitations, life expectancy, and goals for the future. Goals of care for older people with ACS should go beyond clinical outcomes (such as bleeding, stroke, another heart attack, or the need for repeat procedures to reopen arteries). Goals focused on quality of life, the ability to live independently and/or return to their previous lifestyle or living environment are important to consider when planning care for older adults with ACS. Additionally, Do Not Resuscitate (DNR) orders should be discussed prior to any surgery or procedure.
Although the risks are greater, bypass surgery or procedures to reopen a clogged artery are beneficial for some older people with ACS.
If an invasive treatment is chosen, a DNR order may need to be suspended for the duration of the procedure.
If invasive treatment is not chosen, palliative care can help manage symptoms, improve quality of life, and provide psychosocial support.
Important metrics for quality care include measurable goals, such as number of 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 Cardiovascular Diseases in the Elderly Committee of the Council on Clinical Cardiology; Cardiovascular and Stroke Nursing Council; the Board of Radiology and Cardiovascular Intervention; and the Council on Lifestyle and Cardiometabolic Health. Scientific statements from the American Heart Association promote greater awareness of cardiovascular disease and stroke and help facilitate informed healthcare decisions. Scientific statements describe what is currently known about a subject and areas that require further research. Although scientific statements inform guideline development, they do not make treatment recommendations. The American Heart Association guidelines provide the Association’s official clinical practice recommendations.
Co-authors 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. Rich, 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. The authors’ disclosures are listed in the manuscript.
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About the American Heart Association
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