Published online Nov 26, 2020. doi: 10.4330/wjc.v12.i11.513
Peer-review started: April 13, 2020
First decision: April 26, 2020
Revised: July 28, 2020
Accepted: October 12, 2020
Article in press: October 12, 2020
Published online: November 26, 2020
Despite the aging of the population, which makes the clinical presentation of elderly patients with acute myocardial infarction more common, there are no specific guidelines on the management of this subgroup and data are generally extrapolated from trials in which elderly patients represent a minority of the cohort studied. Indeed, controversy exists both on the need for an invasive strategy, especially in frailer patients, and on the optimal medical management.
Exploring and describing the setting of elderly patients with myocardial infarction is particularly useful to identify aspects that need to be improved and sources of mistakes in everyday clinical practice.
In the present real-world study on a population of elderly patients hospitalized due to an acute myocardial infarction, we aimed to investigate our practice during in-hospital time and outcomes during the first year of follow-up.
We retrospectively analyzed all consecutive patients older than 80 years admitted to the Division of Cardiology of our center in 2018 for acute myocardial infarction. Clinical and laboratory data were collected. In-hospital management, consisting of an invasive or conservative strategy, and the anti-thrombotic therapy used were described. Outcomes evaluated at 1 year follow-up included an efficacy ischemic endpoint and a safety bleeding endpoint.
We enrolled a total of 105 patients with a mean age was 83.9 ± 3.6 years. Patients presenting with ST-elevation myocardial infarction (STEMI) (35%) received an invasive treatment in more than 90% of cases, while the number of patients with non-ST-elevation myocardial infarction (NSTEMI) (65%), who underwent coronary angiography and percutaneous angioplasty was lower (38%). Coronary angiography was not performed when the absence of a net clinical benefit was perceived by the treating physicians considering the global risk/benefit ratio, while coronary angioplasty was not performed mainly due to the absence of an obstructive coronary artery disease or technical reasons. Atrial fibrillation, either before or as new onset during the index hospitalization, was found in 24% of patients. With regard to antithrombotic medications, 10.5% of the whole population received triple antithrombotic therapy and 9.5% single antiplatelet therapy plus oral anticoagulation (OAC), with no significant difference between the subgroups, although a higher number of STEMI patients received dual antiplatelet therapy without OAC as compared with NSTEMI patients. A low rate of in-hospital death (5.7%) and 1-year cardiovascular death (3.3%) was registered. Major adverse cardiovascular events were recorded in 7 patients (7.8%). Interestingly, 11 of 14 deaths at one-year follow-up were the result of non-cardiovascular causes, mainly due to malignancy, pneumonia or sepsis. No deaths attributable to bleeding complications were recorded, while only 2 patients experienced a major non-fatal spontaneous bleeding event at follow-up.
The authors of this article acknowledge that specific guidelines on the management of elderly patients with acute coronary syndrome are lacking, yet these patients tend to present with various comorbidities, often associated, and exploring every specific scenario in order to standardize clinical management would be impractical. Trials necessarily restrict enrollment criteria and tend to exclude extreme ages or patients with comorbidities due to the heterogeneity of their clinical presentation. We therefore present a small cohort of patients showing what is likely to be a common scenario in a cardiology ward. We do believe that, in such a complex context, the approach to treatment should be tailored to the patient: Even if a thorough knowledge of the scientific evidence is essential, physicians need to draw on experience and common sense. Through this approach, the rate of complications and death was relatively low in our population. The main limitation of this study, namely its retrospective nature, is somehow a point of strength, as it avoids selection biases which characterize previous studies.
Future studies on the elderly population should be based on a registry design. Larger studies with a higher number of patients enrolled are mandatory.