TREATMENT OF ACUTE CORONARY SYNDROMES IN OLDER ADULTS

Background Despite the increased proportion of elderly patients among those admitted for an acute coronary syndrome (ACS), elderly population has been underrepresented in prospective studies and randomized clinical trials. Nevertheless, older people are often frail, which means that they have low reserve capacity and decreased ability to manage complex physiologic stress, with a significant multimorbidity burden. Accordingly, they deserve dedicated studies to better improve clinical decision making in daily practice. Aim To provide additional information on risk factors and prognosis of elderly patients admitted to hospital for an ACS. Methods The project was based on three post-hoc analyses of the Elderly ACS 2 Randomized Trial- NCT01777503. The trial included ACS patients aged75 years and aimed to compare clopidogrel versus prasugrel 5 mg on top of acetyl salicylic acid for long term secondary prevention and bleeding events. Three main research questions (RQ) were addressed: 1) the role of a specific inflammatory disease (psoriasis) as risk factor for ACS, evaluated within a case-control study; 2) the role of ST-segment elevation myocardial infarction (STEMI) as presenting ACS type as risk factor for cardiovascular, non-cardiovascular death and stroke, evaluated through a cohort study with competing risk analysis; 3) the role of the residual angiographic burden (after percutaneous coronary intervention-PCI) in predicting 1-year mortality and cardiovascular events, evaluated through the change in net benefit (NB) over a core prediction model including the most relevant clinical variables and basal angiographic burden. Results RQ1: The prevalence of psoriasis was lower among cases (12/1455, 0.8%) than among controls (18/1108, 1.6%). The multivariate OR of ACS according to history of psoriasis (adjusted for age, sex and smoking) was 0.51 (95% confidence interval: 0.23–1.09). RQ2: Patients with STEMI had a higher risk of cardiovascular death (cause-specific hazard ratio, cHR 1.85; 95% confidence interval, CI: 1.02-3.36), non-cardiovascular death (cHR 2.10; 95% CI, 1.01-4.38), and stroke (cHR 4.8; 95% CI, 1.7-13.7) as compared to patients with NSTEMI. RQ3: The inclusion of angiographic residual burden gave little incremental value in the standardized NB compared to the core model. Conclusions Our data does not support an association between psoriasis and risk of ACS in the elderly. In these patients, STEMI is an important predictor of cardiovascular death, non-cardiovascular death and stroke. The residual angiographic burden does not improve 1-year prediction of adverse outcome compared with a model including clinical variables and the basal angiographic burden. Elderly patients are a heterogenous, complex, and high- risk group whose management requires a multidimensional clinical approach beyond coronary anatomic variables.