Abstract
Advances in pharmacological treatment and effective early myocardial revascularization have led to improved clinical outcomes in patients with acute myocardial infarction (AMI). However, it has been suggested that compared to younger subjects, elderly AMI patients are less likely to receive evidence-based treatment. Several reasons have been postulated to explain this trend, including uncertainty regarding the benefits of the commonly used interventions in the older age group as well as increased risk associated with comorbidities. The diagnosis, management, and post-hospitalization care of elderly patients presenting with an acute coronary syndrome (ACS) pose many difficulties at present due, at least in part, to the fact that trial data are scanty as elderly patients have been poorly represented in most clinical trials. Thus it appears that these high-risk individuals are often managed with more conservative strategies, compared to younger patients. This article reviews current evidence regarding management of AMI in the elderly.
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Goldberg RJ, Yarzebski J, Lessard D, Gore JM. A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective. J Am Coll Cardiol. 1999;33:1533–9.
Gurwitz JH, Col NF, Avorn J. The exclusion of the elderly and women from clinical trials in acute myocardial infarction. JAMA. 1992;268:1417–22.
Rich MW, Bosner MS, Chung MK, Shen J, McKenzie JP. Is age an independent predictor of early and late mortality in patients with acute myocardial infarction? Am J Med. 1992;92:7–13.
Lee PY, Alexander KP, Hammill BG, Pasquali SK, Peterson ED. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA. 2001;286:708–13.
Britton A, McKee M, Black N, McPherson K, Sanderson C, Bain C. Threats to applicability of randomised trials: exclusions and selective participation. J Health Serv Res Policy. 1999;4:112–21.
Krumholz HM, Gross CP, Peterson ED, Barron HV, Radford MJ, Parsons LS, et al. Is there evidence of implicit exclusion criteria for elderly subjects in randomized trials? Evidence from the GUSTO-1 Study. Am Heart J. 2003;146:839–47.
The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993;329:673–82.
The Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) Angioplasty Substudy Investigators. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. N Engl J Med. 1997;336:1621–8.
A comparison of reteplase with alteplase for acute myocardial infarction. The Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO III) Investigators. N Engl J Med. 1997;337:1118–23.
Van De Werf F, Adgey J, Ardissino D, Armstrong PW, Aylward P, Betriu A, et al. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomized trial. Lancet. 1999;354:716–22.
Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 Investigators. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomized trial in acute myocardial infarction. Lancet. 2001;358:605–13.
Wallentin L, Goldstein P, Armstrong PW, Granger CB, Adgey AA, Arntz HR, et al. Efficacy and safety of tenecteplase in combination with the low-molecular-weight heparin enoxaparin or unfractionated heparin in the prehospital setting: the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 PLUS Randomized Trial in Acute Myocardial Infarction. Circulation. 2003;108:135–42.
White H, Hirulog and Early Reperfusion or Occlusion (HERO)-2 Trial Investigators. Thrombin-specific anticoagulation with bivalirudin versus heparin in patients receiving fibrinolytic therapy for acute myocardial infarction: the HERO-2 randomised trial. Lancet. 2001;358:1855–63.
Champney KP, Frederick PD, Bueno H, Parashar S, Foody J, Merz CN, et al. The joint contribution of sex, age and type of myocardial infarction on hospital mortality following acute myocardial infarction. Heart. 2009;95:895–9.
Avezum A, Makdisse M, Spencer F, Gore JM, Fox KA, Montalescot G, et al. Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE). Am Heart J. 2005;149:67–73.
Topol EJ, GUSTO V Investigators. Reperfusion therapy for acute myocardial infarction with fibrinolytic therapy or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition: the GUSTO V randomised trial. Lancet. 2001;357:1905–14.
Steg PG, Goldberg RJ, Gore JM, Fox KA, Eagle KA, Flather MD, et al. Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE). Am J Cardiol. 2002;90:358–63.
Rogers WJ, Bowlby LJ, Chandra NC, French WJ, Gore JM, Lambrew CT, et al. Treatment of myocardial infarction in the United States (1990 to 1993). Observations from the National Registry of Myocardial Infarction. Circulation. 1994;90:2103–14.
Gillum BS, Graves EJ, Wood E. National hospital discharge survey. Vital Health Stat 13 1998;133:1–51.
Udvarhelyi IS, Gatsonis C, Epstein AM, Pashos CL, Newhouse JP, McNeil BJ. Acute myocardial infarction in the Medicare population. Process of care and clinical outcomes. JAMA. 1992;268:2530–6.
Gurwitz JH, Osganian V, Goldberg RJ, Chen ZY, Gore JM, Alpert JS. Diagnostic testing in acute myocardial infarction: does patient age influence utilization patterns? The Worcester Heart Attack Study. Am J Epidemiol. 1991;134:948–57.
Rosenthal GE, Fortinsky RH. Differences in the treatment of patients with acute myocardial infarction according to patient age. J Am Geriatr Soc. 1994;42:826–32.
Fox KA, Eagle KA, Gore JM, Steg PG, Anderson FA. The Global Registry of Acute Coronary Events, 1999 to 2009–GRACE. Heart. 2010;96:1095–101.
Goodman SG, Huang W, Yan AT, Budaj A, Kennelly BM, Gore JM, et al. The expanded Global Registry of Acute Coronary Events: baseline characteristics, management practices, and hospital outcomes of patients with acute coronary syndromes. Am Heart J. 2009;158:193–201.e1-5.
Rathore SS, Mehta RH, Wang Y, Radford MJ, Krumholz HM. Effects of age on the quality of care provided to older patients with acute myocardial infarction. Am J Med. 2003;114:307–15.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary: a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol. 2004;44:671–719.
Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, et al. ESC Committee for Practice Guidelines (CPG). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2008;29:2909–45.
Kushner FG, Hand M, Smith Jr SC, King 3rd SB, Anderson JL, Antman EM, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2009;54:2205–41.
Krumholz HM, Murillo JE, Chen J, Vaccarino V, Radford MJ, Ellerbeck EF, et al. Thrombolytic therapy for eligible elderly patients with acute myocardial infarction. JAMA. 1997;277:1683–8.
McLaughlin TJ, Soumerai SB, Willison DJ, Gurwitz JH, Gao X, Borbas C, et al. The effect of comorbidity on use of thrombolysis or aspirin in patients with acute myocardial infarction eligible for treatment. J Gen Intern Med. 1997;12:1–6.
Alexander KP, Newby LK, Armstrong PW, Cannon CP, Gibler WB, Rich MW, et al. American Heart Association Council on Clinical Cardiology; Society of Geriatric Cardiology. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115:2570–89.
Grines C, Patel A, Zijlstra F, Weaver WD, Granger C, Simes RJ. Primary coronary angioplasty compared with intravenous thrombolytic therapy for acute myocardial infarction: six-month follow up and analysis of individual patient data from randomized trials. Am Heart J. 2003;145:47–57.
Mehta RH, Rathore SS, Radford MJ, Wang Y, Wang Y, Krumholz HM. Acute myocardial infarction in the elderly: differences by age. J Am Coll Cardiol. 2001;38:736–41.
The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Ethical Principles and guidelines for the Protenction of Human Subjects of Research. Washington: Dept of health, Education and Welfare; 1979. Publication (OS)-78-0013 and (OS)-78-0014.
Weaver WD, Simes RJ, Betriu A, Grines CL, Zijlstra F, Garcia E, et al. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. JAMA. 1997;278:2093–8.
Berger AK, Schulman KA, Gersh BJ, Pirzada S, Breall JA, Johnson AE, et al. Primary coronary angioplasty vs thrombolytics for the management of acute myocardial infarction in elderly patients. JAMA. 1999;282:341–8.
Zijlstra F, de Boer MJ, Hoorntje JC, Reiffers S, Reiber JH, Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med. 1993;328:680–4.
Ribeiro EE, Silva LA, Carneiro R, D'Oliveira LG, Gasquez A, Amino JG, et al. Randomized trial of direct coronary angioplasty versus intravenous streptokinase in acute myocardial infarction. J Am Coll Cardiol. 1993;22:376–80.
Grines CL, Browne KF, Marco J, Rothbaum D, Stone GW, O’Keefe J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med. 1993;328:673–9.
Zijlstra F, Beukema WP, van’t Hof AW, Liem A, Reiffers S, Hoorntje JC, et al. Randomized comparison of primary coronary angioplasty with thrombolytic therapy in low risk patients with acute myocardial infarction. J Am Coll Cardiol. 1997;29:908–12.
Goldenberg I, Matetzky S, Halkin A, Roth A, Di Segni E, Freimark D, et al. Primary angioplasty with routine stenting compared with thrombolytic therapy in elderly patients with acute myocardial infarction. Am Heart J. 2003;145:862–7.
de Boer MJ, Ottervanger JP, van 't Hof AW, Hoorntje JC, Suryapranata H. Reperfusion therapy in elderly patients with acute myocardial infarction. A randomized comparison of primary angioplasty and thrombolytic therapy. J Am Coll Cardiol. 2002;39:1723–28.
Grines C. Senior PAMI: a prospective randomized trial of primary angioplasty and thrombolytic therapy in elderly patients with acute myocardial infarction. TCT 2005; October 16–21, 2005; Washington DC.
Cequier A, Bueno H, Augé JM, Bardají A, Fernández-Ortiz A, Heras M. Characteristics and mortality following primary percutaneous coronary intervention for acute myocardial infarction in Spain. Results from the TRIANA 1 (TRatamiento del Infarto Agudo de miocardio eN Ancianos) Registry. Rev Esp Cardiol. 2005;58:341–50.
Bardají A, Bueno H, Fernández-Ortiz A, Cequier A, Augé JM, Heras M. Type of treatment and short-term outcome in elderly patients with acute myocardial infarction admitted to hospitals with a primary coronary angioplasty facility. The TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) Registry). Rev Esp Cardiol. 2005;58:351–8.
Danzi GB, Centola M, Pomidossi GA, Consonni D, De Matteis S, Stabile A, et al. Usefulness of primary angioplasty in nonagenarians with acute myocardial infarction. Am J Cardiol. 2010;106:770–3.
Fosbol EL, Thune JJ, Kelbaek H, Andersen HR, Saunamaki K, Nielsen TT, et al. Longterm outcome of primary angioplasty compared with fibrinolysis across age groups: a Danish multicenter randomized study on fibrinolytic therapy versus acute coronary angioplasty in acute myocardial infarction (DANAMI-2) substudy. Am Heart J. 2008;156:391–6.
Antoniucci D, Valenti R, Santoro GM, Bolognese L, Moschi G, Trapani M, et al. Systematic primary angioplasty in octogenarian and older patients. Am Heart J. 1999;138:670–4.
Bueno H, Betriu A, Heras M, Alonso JJ, Cequier A, García EJ, et al. Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J. 2011;32:51–60.
Senior PAMI. Primary angioplasty versus thrombolytic therapy for acute myocardial infarction in the elderly. http://www.clinicaltrial.gov/ct2/show/NCT00136929. (20 February 2011)
Capodanno D, Angiolillo DJ. Antithrombotic therapy in the elderly. J Am Coll Cardiol. 2010;56:1683–92.
Alexander KP, Chen AY, Roe MT, Newby LK, Gibson CM, Allen-LaPointe NM, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA. 2005;294:3108–16.
Curtis JP, Alexander JH, Huang Y, Wallentin L, Verheugt FW, Armstrong PW, et al. Efficacy and safety of two unfractionated heparin dosing strategies with tenecteplase in acute myocardial infarction (results from Assessment of the Safety and Efficacy of a New Thrombolytic Regimens 2 and 3). Am J Cardiol. 2004;94:279–83.
Antman EM, Morrow DA, McCabe CH, Murphy SA, Ruda M, Sadowski Z, et al. Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction. N Engl J Med. 2006;354:1477–88.
Sabatine MS, Cannon CP, Gibson CM, Lopez Sendon JL, Montalescot G, Theroux P, et al. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. 2005;352:1179–89.
Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J, Granger CB, et al. Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial. JAMA. 2006;295:1519–30.
Madsen JK, Chevalier B, Darius H, Rutsch W, Wójcik J, Schneider S, et al. Ischaemic events and bleeding in patients undergoing percutaneous coronary intervention with concomitant bivalirudin treatment. EuroIntervention. 2008;3:610–6.
Chen ZM, Jiang LX, Chen YP, Xie JX, Pan HC, Peto R, et al. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo controlled trial. Lancet. 2005;366:1607–21.
Wiviott SD, Antman EM, Gibson CM, Montalescot G, Riesmeyer J, Weerakkody G, et al. Evaluation of prasugrel compared with clopidogrel in patients with acute coronary syndromes: design and rationale for the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet InhibitioN with prasugrel Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38). Am Heart J. 2006;152:627–35.
Wiviott SD, Braunwald E, McCabe CH, French PA, Smyth SS, Becker RC. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357:2001–15.
Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51:210–47.
US Food and Drug Administration (FDA). Cardiovascular and renal drug advisory committee briefing document on prasugrel for ACS. 2009. http://www.fda.gov/ohrms/dockets/ac/09/briefing/2009-4412b1-01-FDA.pdf (accessed 21 February 2010).
Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361:1045–57.
Horwitz PA, Berlin JA, Sauer WH, Laskey WK, Krone RJ, Kimmel SE, et al. Bleeding risk of platelet glycoprotein IIb/IIIa receptor antagonists in broad-based practice (results from the Society for Cardiac Angiography and Interventions Registry). Am J Cardiol. 2003;91:803–6.
Brown DL. Deaths associated with platelet glycoprotein IIb/IIIa inhibitor treatment. Heart. 2003;89:535–7.
Montalescot G, Barragan P, Wittenberg O, Ecollan P, Elhadad S, Villain P, et al. Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med. 2001;344:1895–903.
Prasad A, Stone GW, Aymong E, Zimetbaum PJ, McLaughlin M, Mehran R, et al. Impact of ST-segment resolution after primary angioplasty on outcomes after myocardial infarction in elderly patients: an analysis from the CADILLAC trial. Am Heart J. 2004;147:669–75.
Sadeghi HM, Grines CL, Chandra HR, Dixon SR, Boura JA, Dukkipati S, et al. Percutaneous coronary interventions in octogenarians. glycoprotein IIb/IIIa receptor inhibitors' safety profile. J Am Coll Cardiol. 2003;42:428–32.
Dziewierz A, Siudak Z, Rakowski T, Chyrchel M, Mielecki W, Janzon M, et al. Early abciximab administration before primary percutaneous coronary intervention improves clinical outcome in elderly patients transferred with ST-elevation myocardial infarction: data from the EUROTRANSFER registry. Int J Cardiol. 2010;143:147–53.
Rich MW; PRICE-2 Organizing Committee; PRICE-2 Investigators. Executive summary: Second Pivotal Research in Cardiovascular Syndromes in the Elderly (PRICE-2) symposium. Acute coronary syndromes in the elderly: mechanisms and management. Am J Geriatr Cardiol. 2003;12:307–18, 327.
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Carro, A., Bastiaenen, R. & Kaski, J.C. Age Related Issues in Reperfusion of Myocardial Infarction. Cardiovasc Drugs Ther 25, 139–148 (2011). https://doi.org/10.1007/s10557-011-6288-6
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DOI: https://doi.org/10.1007/s10557-011-6288-6