2019 Vol. 16, No. 2
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2019, 16(2): 67-99.
doi: 10.11909/j.issn.1671-5411.2019.02.001
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2019, 16(2): 100-102.
doi: 10.11909/j.issn.1671-5411.2019.02.003
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2019, 16(2): 103-113.
doi: 10.11909/j.issn.1671-5411.2019.02.006
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With population ageing and rise of life expectancy, a progressively increasing proportion of patients presenting with an acute coronary syndrome (ACS) are older adults, including those at extreme chronological age. Increasing amounts of data, including randomized clinical trials, have shown that the benefits of an early revascularization are maintained also at very old age, resulting in improved outcome after an acute coronary event. On the contrary, the optimal antiplatelet therapy (APT) remains unclear in these patients, because of both safety and efficacy concerns. Indeed, age-related multiple organ dysfunction and high prevalence of comorbidities may on the one hand reduce the therapeutic effects of administered drugs; on the other hand, it leads to increased vulnerability to drug toxicity and side effects. Therefore, management of APT is particularly challenging in elderly patients because of higher risk of both ischemic and bleeding events. The aim of the present paper is to review the current evidence, gaps in knowledge and on-going research regarding APT in the setting of an ACS in elderly and very elderly patients, and in those with significant comorbidities including chronic kidney disease, diabetes mellitus and frailty.
With population ageing and rise of life expectancy, a progressively increasing proportion of patients presenting with an acute coronary syndrome (ACS) are older adults, including those at extreme chronological age. Increasing amounts of data, including randomized clinical trials, have shown that the benefits of an early revascularization are maintained also at very old age, resulting in improved outcome after an acute coronary event. On the contrary, the optimal antiplatelet therapy (APT) remains unclear in these patients, because of both safety and efficacy concerns. Indeed, age-related multiple organ dysfunction and high prevalence of comorbidities may on the one hand reduce the therapeutic effects of administered drugs; on the other hand, it leads to increased vulnerability to drug toxicity and side effects. Therefore, management of APT is particularly challenging in elderly patients because of higher risk of both ischemic and bleeding events. The aim of the present paper is to review the current evidence, gaps in knowledge and on-going research regarding APT in the setting of an ACS in elderly and very elderly patients, and in those with significant comorbidities including chronic kidney disease, diabetes mellitus and frailty.
2019, 16(2): 114-120.
doi: 10.11909/j.issn.1671-5411.2019.02.004
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Elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes (ACS). The optimal management of ACS in these patients is still a challenge due to their clinical peculiarities and the paucity of specific data, and they have been traditionally managed more conservatively mainly based on subjective criteria. In ST-segment elevation acute myocardial infarction urgent reperfusion is the standard of care and there is no upper age limit. In non-ST segment elevation acute myocardial infarction evidence is controversial, incomplete and mainly focused on chronological age. While a strict conservative strategy should be avoided, routine invasive strategy may reduce the occurrence of myocardial infarction and need for revascularization at follow-up with no established benefit in terms of mortality. Clinical characteristics associated with aging, such as comorbidities and frailty, further discriminate patient’s risk beyond age. Evidence is scarce, but it suggests that these features may modulate the benefit of invasive strategy in this population. Ongoing trials should clarify the optimal management of ACS based on these parameters.
Elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes (ACS). The optimal management of ACS in these patients is still a challenge due to their clinical peculiarities and the paucity of specific data, and they have been traditionally managed more conservatively mainly based on subjective criteria. In ST-segment elevation acute myocardial infarction urgent reperfusion is the standard of care and there is no upper age limit. In non-ST segment elevation acute myocardial infarction evidence is controversial, incomplete and mainly focused on chronological age. While a strict conservative strategy should be avoided, routine invasive strategy may reduce the occurrence of myocardial infarction and need for revascularization at follow-up with no established benefit in terms of mortality. Clinical characteristics associated with aging, such as comorbidities and frailty, further discriminate patient’s risk beyond age. Evidence is scarce, but it suggests that these features may modulate the benefit of invasive strategy in this population. Ongoing trials should clarify the optimal management of ACS based on these parameters.
2019, 16(2): 121-128.
doi: 10.11909/j.issn.1671-5411.2019.02.008
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Background Elderly patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) may present delirium but its clinical relevance is unknown. This study aimed at determining the clinical associated factors, and prognostic implications of delirium in old-aged patients admitted for NSTE-ACS. Methods LONGEVO-SCA is a prospective multicenter registry including unselected patients with NSTE-ACS aged ≥ 80 years. Clinical variables and a complete geriatric evaluation were assessed during hospitalization. The association between delirium and 6-month mortality was assessed by a Cox regression model weighted for a propensity score including the potential confounding variables. We also analysed its association with 6-month bleeding and cognitive or functional decline. Results Among 527 patients included, thirty-seven (7%) patients presented delirium during the hospitalization. Delirium was more frequent in patients with dementia or depression and in those from nursing homes (27.0% vs. 3.1%, 24.3% vs. 11.6%, and 11.1% vs. 2.2%, respectively; all P vs. 5.3%, P vs. 49.8%, P = 0.02). Patients with delirium had longer hospitalizations [median 8.5 (5.5-14) vs. 6.0 (4.0-10) days, P = 0.02] and higher incidence of 6-month bleeding and mortality (32.3% vs. 10.0% and 24.3% vs. 10.8%, respectively; both P P = 0.04) and 6-month bleeding events (OR = 2.87; 95% CI: 1.98-4.16, P Conclusions In-hospital delirium in elderly patients with NSTE-ACS is associated with some preventable risk factors and it is an independent predictor of 6-month mortality.
Background Elderly patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) may present delirium but its clinical relevance is unknown. This study aimed at determining the clinical associated factors, and prognostic implications of delirium in old-aged patients admitted for NSTE-ACS. Methods LONGEVO-SCA is a prospective multicenter registry including unselected patients with NSTE-ACS aged ≥ 80 years. Clinical variables and a complete geriatric evaluation were assessed during hospitalization. The association between delirium and 6-month mortality was assessed by a Cox regression model weighted for a propensity score including the potential confounding variables. We also analysed its association with 6-month bleeding and cognitive or functional decline. Results Among 527 patients included, thirty-seven (7%) patients presented delirium during the hospitalization. Delirium was more frequent in patients with dementia or depression and in those from nursing homes (27.0% vs. 3.1%, 24.3% vs. 11.6%, and 11.1% vs. 2.2%, respectively; all P vs. 5.3%, P vs. 49.8%, P = 0.02). Patients with delirium had longer hospitalizations [median 8.5 (5.5-14) vs. 6.0 (4.0-10) days, P = 0.02] and higher incidence of 6-month bleeding and mortality (32.3% vs. 10.0% and 24.3% vs. 10.8%, respectively; both P P = 0.04) and 6-month bleeding events (OR = 2.87; 95% CI: 1.98-4.16, P Conclusions In-hospital delirium in elderly patients with NSTE-ACS is associated with some preventable risk factors and it is an independent predictor of 6-month mortality.
2019, 16(2): 129-137.
doi: 10.11909/j.issn.1671-5411.2019.02.005
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Frailty is an issue of paramount importance for cardiologists, because of the aging of patients admitted to hospital for acute coronary syndrome (ACS) and the straight relationship between aging and frailty. Several tools have been provided in this setting, in order to objectively assess frailty status, but important questions are still unsolved. There are conflicting data about a unique definition of frailty in subjects with cardiovascular diseases, the timing to perform a frailty evaluation in the context of an acute myocardial infarction, the mean to assess frailty in these patients and the usefulness of the information derived from the frailty assessment. Frailty results from the analysis of several items and a multidomain evaluation including laboratory values, clinical data and physical performance assessment is required for a comprehensive frailty assessment. However, regardless of the frailty tool, the prevalence of frailty in older ACS patients is high and it could add important information to the decision-making process about invasive strategy, the multivessel disease management, dual antiplatelet therapy and secondary prevention programs. The present overview tries to summarize the current knowledge about the definition and prevalence of frailty in older adults admitted to hospital for ACS, suggesting how frailty assessment may improve the management of older ACS patients.
Frailty is an issue of paramount importance for cardiologists, because of the aging of patients admitted to hospital for acute coronary syndrome (ACS) and the straight relationship between aging and frailty. Several tools have been provided in this setting, in order to objectively assess frailty status, but important questions are still unsolved. There are conflicting data about a unique definition of frailty in subjects with cardiovascular diseases, the timing to perform a frailty evaluation in the context of an acute myocardial infarction, the mean to assess frailty in these patients and the usefulness of the information derived from the frailty assessment. Frailty results from the analysis of several items and a multidomain evaluation including laboratory values, clinical data and physical performance assessment is required for a comprehensive frailty assessment. However, regardless of the frailty tool, the prevalence of frailty in older ACS patients is high and it could add important information to the decision-making process about invasive strategy, the multivessel disease management, dual antiplatelet therapy and secondary prevention programs. The present overview tries to summarize the current knowledge about the definition and prevalence of frailty in older adults admitted to hospital for ACS, suggesting how frailty assessment may improve the management of older ACS patients.
2019, 16(2): 138-144.
doi: 10.11909/j.issn.1671-5411.2019.02.007
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There are important sex-related differences in elderly patients with acute coronary syndrome (ACS). Women are older, more frequently frail, and present more comorbidities than men. Atypical symptoms at presentation are also more common in female patients, they are leaded to a delayed diagnosis and treatment. Coronary angiography and subsequent revascularization are frequently underused in elderly women and they tend to receive less guidelines-recommended therapies. The prognosis in elderly frail women with ACS is poor, and it is with high mortality and readmissions rates. Bleeding is recurrent ischemic events in which it is more frequent in women than in men. Recovery time might be long, and a multidisciplinary approach is desirable to improve prognosis and quality of life. Further studies are needed in order to clarify the benefit of the different therapies in the group of frail women, and this is particularly true for revascularization, as scientific evidence in this group is very scarce.
There are important sex-related differences in elderly patients with acute coronary syndrome (ACS). Women are older, more frequently frail, and present more comorbidities than men. Atypical symptoms at presentation are also more common in female patients, they are leaded to a delayed diagnosis and treatment. Coronary angiography and subsequent revascularization are frequently underused in elderly women and they tend to receive less guidelines-recommended therapies. The prognosis in elderly frail women with ACS is poor, and it is with high mortality and readmissions rates. Bleeding is recurrent ischemic events in which it is more frequent in women than in men. Recovery time might be long, and a multidisciplinary approach is desirable to improve prognosis and quality of life. Further studies are needed in order to clarify the benefit of the different therapies in the group of frail women, and this is particularly true for revascularization, as scientific evidence in this group is very scarce.
2019, 16(2): 145-150.
doi: 10.11909/j.issn.1671-5411.2019.02.002
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Nowadays, elderly people represent a growing population segment with a well-known increased risk of both ischemic and bleeding events. Current acute coronary syndrome guidelines, strongly recommend dual antiplatelet therapy (DAPT) with few specific references for aged patients due to lack of evidence. Patients aged ≥ 75 years are misrepresented in the classic derivation trials cohorts.Strategies to reduce the bleeding risk in this group of patients are urgently needed for the daily clinical practice. Identify the specific age related bleeding risk factors and the importance of an integral geriatric assessment remains challenging. Some of the available in-hospital and out-hospital bleeding risk scores have shown a lower to moderate predictive ability in older patients and no specific tools are developed in elderly population. The importance of an appropriate vascular access choice, type and duration of antiplatelet drugs is crucial to reduce the bleeding risk. Increase radial approaches and short DAPT duration leads to reduce hemorrhages. One interesting subgroup of patients is those who need chronic anticoagulation therapy after percutaneous coronary intervention, due to their very high risk of bleeding. New alternatives as dual therapy with oral anticoagulation and only one antiplatlet drug should be considered. In current review, we evaluate the available evidence about bleeding risk in elderly.
Nowadays, elderly people represent a growing population segment with a well-known increased risk of both ischemic and bleeding events. Current acute coronary syndrome guidelines, strongly recommend dual antiplatelet therapy (DAPT) with few specific references for aged patients due to lack of evidence. Patients aged ≥ 75 years are misrepresented in the classic derivation trials cohorts.Strategies to reduce the bleeding risk in this group of patients are urgently needed for the daily clinical practice. Identify the specific age related bleeding risk factors and the importance of an integral geriatric assessment remains challenging. Some of the available in-hospital and out-hospital bleeding risk scores have shown a lower to moderate predictive ability in older patients and no specific tools are developed in elderly population. The importance of an appropriate vascular access choice, type and duration of antiplatelet drugs is crucial to reduce the bleeding risk. Increase radial approaches and short DAPT duration leads to reduce hemorrhages. One interesting subgroup of patients is those who need chronic anticoagulation therapy after percutaneous coronary intervention, due to their very high risk of bleeding. New alternatives as dual therapy with oral anticoagulation and only one antiplatlet drug should be considered. In current review, we evaluate the available evidence about bleeding risk in elderly.
2019, 16(2): 151-155.
doi: 10.11909/j.issn.1671-5411.2019.02.009
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2019, 16(2): 156-163.
doi: 10.11909/j.issn.1671-5411.2019.02.012
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Background Few data on the combined effects of bifurcation and calcification on coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI) are available. This study evaluated the impact of main vessel (MV) calcification on the procedural and long-term outcomes in patients with CAD who underwent provisional single stent PCI. Methods This is a multicenter, prospective, observational study. Patients with bifurcation lesions were enrolled at 10 PCI centers in China from January 2015 to December 2017. Intravascular ultrasound or optical coherence tomography was performed in all patients to evaluate the MV calcification. Patients were treated with provisional single stent strategy using drug eluting stents and followed-up at 1 month, 6 months and 12 months after discharge by telephone contact or outpatient visit. Repeated coronary imaging was performed within one year. We compared the procedural success rates in MV and in side-branch (SB), and target lesion failure (TLF), defined as a composite of cardiac death, non-fatal myocardial infarction, definite or possible stent thrombosis and target lesion revascularization between patients with and without MV calcification. Results A total of 185 subjects were enrolled according to the inclusion and exclusion criteria of this study. MV calcification was detected in 119 (64.3%, calcification group) and not found in 66 (35.7%, non-calcification group) patients. The angiographic success rate of MV was 95.8% in the calcification group and 97.0% in the non-calcification group (P = 0.91); the angiographic success rate of SB was 32.8% in the calcification group and 53.0% in the non-calcification group (P P = 0.31). Multivariate regression analysis showed the same result (HR = 1.23, 95% CI: 0.76-1.52, P = 0.47). Calcification on group had higher recurrent angina than non-calcification group (13.51% vs. 17.65%, P Conclusions In patients with coronary bifurcation lesion treated with provisional one stent approach, calcification of MV is associated with lower SB procedural success rate, it could increase recurrence of angina; however, it was not associated with an increased risk of TLF.
Background Few data on the combined effects of bifurcation and calcification on coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI) are available. This study evaluated the impact of main vessel (MV) calcification on the procedural and long-term outcomes in patients with CAD who underwent provisional single stent PCI. Methods This is a multicenter, prospective, observational study. Patients with bifurcation lesions were enrolled at 10 PCI centers in China from January 2015 to December 2017. Intravascular ultrasound or optical coherence tomography was performed in all patients to evaluate the MV calcification. Patients were treated with provisional single stent strategy using drug eluting stents and followed-up at 1 month, 6 months and 12 months after discharge by telephone contact or outpatient visit. Repeated coronary imaging was performed within one year. We compared the procedural success rates in MV and in side-branch (SB), and target lesion failure (TLF), defined as a composite of cardiac death, non-fatal myocardial infarction, definite or possible stent thrombosis and target lesion revascularization between patients with and without MV calcification. Results A total of 185 subjects were enrolled according to the inclusion and exclusion criteria of this study. MV calcification was detected in 119 (64.3%, calcification group) and not found in 66 (35.7%, non-calcification group) patients. The angiographic success rate of MV was 95.8% in the calcification group and 97.0% in the non-calcification group (P = 0.91); the angiographic success rate of SB was 32.8% in the calcification group and 53.0% in the non-calcification group (P P = 0.31). Multivariate regression analysis showed the same result (HR = 1.23, 95% CI: 0.76-1.52, P = 0.47). Calcification on group had higher recurrent angina than non-calcification group (13.51% vs. 17.65%, P Conclusions In patients with coronary bifurcation lesion treated with provisional one stent approach, calcification of MV is associated with lower SB procedural success rate, it could increase recurrence of angina; however, it was not associated with an increased risk of TLF.
2019, 16(2): 164-167.
doi: 10.11909/j.issn.1671-5411.2019.02.011
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2019, 16(2): 168-172.
doi: 10.11909/j.issn.1671-5411.2019.02.010
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