How heart attacks and heart-related chest pain are treated may need to be modified for people 75 and older because of age-related changes in the heart and blood vessels as well as overall health, according to a new report from the American Heart Association.
The scientific statement, published Monday in Circulation, highlights recent evidence to help medical professionals care for older adults. It updates a 2007 statement.
According to the new statement, 30%-40% of people hospitalized for acute coronary syndrome, or ACS – the medical term to describe heart attacks and heart-related chest pain known as unstable angina – are 75 and older.
People in this age group are often excluded from the research used to develop clinical practice guidelines “because their health care needs are more complex” than younger patients, writing committee chair, Dr. Abdulla A. Damluji, said in a news release. He is director of the Inova Center of Outcomes Research in Fairfax, Virginia, and an associate professor of medicine at Johns Hopkins School of Medicine in Baltimore.
“Older patients have more pronounced anatomical changes and more severe functional impairment, and they are more likely to have additional health conditions,” Damluji said. “These include frailty, other chronic disorders (treated with multiple medications), physical dysfunction, cognitive decline and/or urinary incontinence – and these are not regularly studied in the context of ACS.”
Cardiovascular changes associated with the aging process raise the risk for ACS and make diagnosing and treating it more complicated. These changes include large arteries becoming stiffer; the heart muscle pumping less effectively; blood vessels becoming less flexible and less able to adapt to the heart’s changing oxygen needs; and an increased tendency to form blood clots.
Other changes associated with aging – such as poor kidney function – may also need to be considered when diagnosing and treating ACS in older adults. For example, agents used in some imaging tests can harm the kidneys as their function declines.
The method used to determine whether a person has had a heart attack also needs to change, the report suggests. Elevated troponin levels typically signal that a heart attack has occurred, but older adults with kidney disease and stiffened heart muscles may already have higher levels of the enzyme. In these cases, it may be more appropriate to evaluate whether troponin levels are rising or falling to determine if a heart attack has occurred.
Symptoms of ACS can differ in older adults, the statement notes. For example, rather than chest pain, symptoms instead might include shortness of breath, fainting or sudden confusion.
It’s also important not to forego some treatments that could benefit older patients, such as cardiac rehabilitation, an important component in helping people recover functionality following a heart attack. The statement notes that health care professionals sometimes avoid sending older heart patients to rehab because they are frail, but research shows these are the patients who benefit most from such services.
How medications are prescribed and managed also may need to change. Because older people often take multiple medications, it’s important to look out for harmful drug interactions. When patients are moved from one facility to another, it’s also important to make sure medications continue to be given without interruption.
For people with cognitive difficulties and limited mobility, simplified medication plans with fewer doses per day and 90-day supplies to prevent the need for frequent refills also may help, according to the statement.
“Geriatric syndromes and the complexities of their care may undermine the effectiveness of treatments for ACS, as well as the resiliency of older adults” in their recovery, Damluji said. “A detailed review of all medications – including supplements and over-the-counter medicines – is essential, ideally in consultation with a pharmacist who has geriatric expertise.”
The statement recommends individualized patient care plans for older people with ACS, with input from a multidisciplinary team that may include cardiologists, surgeons, geriatricians, primary care doctors, nutritionists, social workers and family members. Procedures such as bypass surgery, though riskier for older adults, may still be beneficial for some, and the risks and benefits should be discussed. It’s also important to discuss whether the patient has a do not resuscitate order and whether it should be suspended during some surgical procedures.
The committee highlighted the importance of monitoring progress – including a patient’s ability to function and their quality of life – following hospital discharge. Goals for older people with ACS may extend beyond medical outcomes to quality of life goals such as being able to function independently or return to their previous lifestyle.
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