Acute coronary syndrome in elderly: aspects of patient management

Coronary heart disease is the leading cause of death worldwide. Over the past few decades, life expectancy has increased, which has led to an aging population in developed countries, so the average age of patients with acute coronary syndrome (ACS) has steadily increased in recent decades. The inclusion of elderly and senile patients in randomized clinical trials does not reflect the age-related association of these diseases. However, antithrombotic therapy and interventional treatment are the basis of treatment in patients with ACS of any age, including the elderly. For older patients, there may be a mismatch between chronological and biological age. The question of how close the treatment of elderly patients with ACS is to the level of current recommendations and whether it is possible to apply them unconditionally in this group of patients does not have a definite answer. Current recommendations and the underlying randomized clinical trials are focused on any one disease, whereas in the elderly in most cases multimorbid pathology occurs. In general, elderly patients with ACS should be treated using the same methods as younger patients, however, the presence of comorbid diseases in an elderly patient naturally increases the risk of complications, makes the patient’s prognosis heavier, significantly affects treatment tactics, limits the possibility of using conventional approaches when choosing a drug therapy

The choice of the P2Y12 receptors blocker in the treatment of a patient with acute coronary syndrome: practice of N.I. Pirogov city clinical hospital №1

Ticagrelor is known to prefer clopidigrel except in cases of high risk of bleeding, but according to the literature, clopidogrel still remains the most frequent second component of dual antiplatelet therapy (DAPT) in the world. The aim of the study was to conduct comparative description of patient groups with the acid acetilsalicilic (ACS), taken depending on a prescription of clopidogrel or ticagrelor as the second component of DAPT according to data of the year’s work of the Pirogov City Clinical Hospital №1. Materials and methods: clinical data of 854 patients with ACS who undergone treatment in of Pirogov City Clinical Hospital №1 in 2017 were analyzed. Clopidogrel was prescribed to 623 patients (73%) – the I group, ticagrelor 231 (27%) – the II group. Patients in the I group compared to the II group were significantly older (70 and 62 years accordingly), women accounted for 43% in I group and 27% in II group. Arterial hypertension (96 and 89%), diabetes (34 and 26%), post-acute myocardial infarction (38 and 19%), chronic kidney disease (26 and 12%), anemia (15 and 7%). Among patients of II group final diagnosis of ST-elevation myocardial infarction (STEMI) was more often (64 and 31%), coronary angiography (CAG) and percutaneous coronary intervention (PCI) were more frequent – 98/94% and 88/75%, accordingly. Clopidogrel is prescribed to the patients more often in comparison with ticagrelor. Doctors make a choice in favor of clopidogrel for elderly patients, more often women and more comorbid patients. The presence of STEMI, as well as the performance of CAG / PCI in any definitive diagnosis, is associated with a relatively more frequent prescription of ticagrelor, and in elderly patients, the implementation of PCI is the only factor that significantly influences the choice of more active antiaggregant in DAPT

Antithrombotic Therapy after Bleeding in Elderly Polimorbid Patient: Our Time Challenge

In recent years, there has been a clear trend towards an increase in the number of elderly patients suffering from several polymorbid diseases, which considerably complicates the forecast and tactics of management. A clinical case of an elderly patient, suffering for a long time from type 2 diabetes mellitus, receiving insulin and treated with programmed hemodialysis due to terminal chronic renal failure, and suffering from atrial fibrillation in permanent form, is presented. The patient was hospitalized in theCityClinicalHospital№1 named after N.I. Pirogov due to acute repeated myocardial infarction. An emergency percutaneous coronary intervention was performed, the infarct-dependent artery was stented with a drug-eluted stent. The postoperative period complicated by the development of acute blood loss associated with bleeding from the upper sections of the gastrointestinal tract, and severe anemia of the combined genesis (posthemorrhagic, renal). This situation required doctors to make non-standard decisions in the choice of antithrombotic therapy. This clinical case illustrates the difficulties in elderly polymorbid patient management in real clinical practice and the controversial issues arising in the prescribing the antithrombotic therapy, especially after bleeding had developed. The supporting guidelines cannot answer all the questions which the daily practice poses to the doctor. In each case, the resumption of antithrombotic therapy and its optimal choice for an elderly polymorbid patient with developed bleeding is the subject of discussion and presented a real challenge for the treating physician

How Does the Presence of Diabetes Affect the Course of Acute Coronary Syndrome in Elderly Patients in Actual Clinical Practice?

The number of elderly patients with diabetes mellitus (DM) is constantly growing in general population. Accordantly, we have the growth of such patients in the group of acute coronary syndrome (ACS).Aim. To compare clinical characteristics of the elderly patient (>75 years old) with and without DM.Material and methods. This retrospective study included 1133 ACS patients who were aged ≥75 years and admitted to the City Clinical Hospital №1 from 01.01.2015 to 31.12.2016. Median age was 80 years, 66% were women. We analyzed 4 patient subgroups: Group 1 – 105 patients with ST-segment elevation myocardial infarction (STEMI) and DM, Group 2 – 254 STEMI patients without DM, Group 3 – 222 non-STEMI patients with DM and Group 4 – 552 non-STEMI patients without DM. We used Student’s t-test and c2 tests to find significant difference between pairs of groups.Results. Median age of patients in 4 groups was 80, 81, 81 and 80 years (p>0.05), age variance was 75-100 years. DM was found in 29% of all elderly patients with no difference between STEMI and non-STEMI groups. STEMI and non-STEMI patients with DM were more likely women. NonSTEMI patients with DM more often had hypertension, previous stroke, lower median Hb (121 vs 127 g/l; p<0.001). Angiography data demonstrated more often three-vessel disease (43% vs 29.7%) and less one-vessel disease (15% vs 25.6%; p<0.05) between groups 3 and 4. Glomerular filtration rate (GFR) <60 ml/min/1.73 m2 occurred in 74%, 73%, 77% and 74% in patients of 4 groups (p>0,05), but GFR<45 ml/min/1.73 m2 was more prevalent in patients with DM than without DM: 45%, 39%, 45%, 36% in 4 groups. Finally, mortality rates didn’t demonstrate significant difference between DM and non-DM patients with STEMI (10% vs 13%; p>0.05) and non-STEMI (7% vs 7%) groups.Conclusion. DM is associated with ACS approximately in one third of the elderly patients and is not associated with its type (STEMI or non-STEMI). In STEMI and non-STEMI patients the female sex and GFR level <45 ml/min/1.73 m2 were associated with DM. In non-STEMI group multi-vessel disease and presence of hypertension and previous stroke were associated with DM. We didn’t find any difference between mortality in elderly patients with and without DM

Comorbidities and Percutaneous Coronary Intervention in Elderly Patients with Acute Coronary Syndrome

Aim. To assess comorbidities in elderly patients with acute coronary syndrome (ACS) and to analyze patient subgroups with different treatment strategies in the Regional Vascular Center (RVC).Material and methods. The prospective study included 205 patients with confirmed ACS 75 years and older, the mean age was 81±4.9 years, and 68% were women. ST segment elevation myocardial infarction (STEMI) was diagnosed in 46 (22.4 %) patients, non-ST segment elevation myocardial infarction (NSTEMI) was diagnosed in 159 (77,6 %) patients. The Charlson Comorbidity Index (CCI) was calculated in every patient. Early outcomes were defined as those assessed during hospital stay. Late outcomes were assessed at 6 months after the discharge using phone calls and/or clinic visits. All patients provided written informed consent.Results. Percutaneous coronary intervention (PCI) was performed in 42% of patients. In patients with STEMI and NSTEMI PCI was performed in 73% and 32%, respectively. Mean CCI score was 7.9 points: 7.6 points in men and 8.04 in women. Patients with STEMI had higher CCI score than NSTEMI patients (p<0.01): 8.1 points and 7.1 points, respectively. Patients who underwent PCI had lower CCI score (7.2 points) than patients in non-PCI group (8.2 points; p<0.05). Patients with STEMI in PCI and non-PCI groups had significant difference in CCI score (p<0.05): 7.4 and 8.4 points, respectively. Mean CCI score in patients who died in hospital was 8.5 while discharged patients had 7.6 points (p<0.01). In 6 months 13 patients (6.3%) died, their mean age was 84.9 years, mean CCI was 9 points, PCI was performed in 3 (23%) patients.Conclusions. Elderly patients with ACS had high comorbidity level assessed by CCI score. Higher CCI score was associated with PCI non-performance in elderly patients. Elderly patients with STEMI had higher CCI score than patients with NSTEMI which was significantly associated with PCI non-performance. Patients who died in hospital or in 6 months after the ACS onset had higher CCI score than other elderly patients with ACS