NSTE-ACS in Older Adults

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Questions and Answers

Which of the following statements is TRUE regarding NSTE-ACS in older individuals?

  • Older patients with NSTE-ACS are more likely to be men.
  • Older patients with NSTE-ACS are more likely to have lower body mass indices. (correct)
  • Older patients with NSTE-ACS are less likely to have comorbidities like hypertension.
  • Older patients with NSTE-ACS are more likely to have higher body mass indices.

The mortality rate after a first non-STEMI in the oldest old patients is ______, increasing progressively with age groups.

highest

Age is solely a predictor of cardiovascular disease and not an independent risk factor for adverse outcomes after CVD events.

False (B)

What is a significant challenge in diagnosing NSTE-ACS in older patients?

<p>A high index of suspicion is necessary.</p> Signup and view all the answers

Match the following age groups with their corresponding 1-year mortality rates after a first non-STEMI.

<p>65 - 79 = 13.3% 80 - 84 = 23.6% 85 - 89 = 33.6% At least 90 = 45.5%</p> Signup and view all the answers

What percentage of patients aged over 85 years had chest pain on presentation?

<p>40% (B)</p> Signup and view all the answers

Elevated troponins are uncommon in patients aged over 70 years.

<p>False (B)</p> Signup and view all the answers

What is the conventional cut-off value (99th percentile) for troponin levels?

<p>0.014 ng/mL</p> Signup and view all the answers

Mild elevations of hs-cTnT levels are common in older patients, and increased hs-cTn levels are an independent ___ in this population.

<p>prognostic marker</p> Signup and view all the answers

Why is the strength of recommendations for older adults lower than for younger adults?

<p>Fewer studies have been conducted in older adults. (C)</p> Signup and view all the answers

The biological age of a patient should be considered over their chronological age when making management decisions.

<p>True (A)</p> Signup and view all the answers

What future cardiac events were elevations in cTn associated with in older women?

<p>Future cardiac events in older women without apparent clinical manifestations.</p> Signup and view all the answers

Match the following age-related terms with their descriptions:

<p>Chronological age = Actual age measured in years Biological age = Age determined by health and physical condition Troponin = Cardiac biomarker associated with heart injury Comorbidities = Existing health conditions that coexist with the primary condition</p> Signup and view all the answers

What should be calculated to enable appropriate drug dosing in older adults?

<p>Creatinine clearance (B)</p> Signup and view all the answers

Clopidogrel is the recommended P2Y12 inhibitor for older persons aged 65 years.

<p>False (B)</p> Signup and view all the answers

What is the reduced dose of Prasugrel recommended for patients older than 75 years?

<p>5mg</p> Signup and view all the answers

Both UFH and LMWH are equally effective in older adults, but the bleeding risk is high with both agents, and should be dosed at _____ mg/kg twice daily in patients aged ≥75 years.

<p>0.75-1.0</p> Signup and view all the answers

Match the following interventions with their recommended practices for older adults:

<p>Aspirin = Confer greater benefits in older adults Clopidogrel = P2Y12 inhibitor of choice in patients &gt; 75 Prasugrel = Reduced dose of 5mg for patients &gt; 75 Fondaparinux = Recommended for less bleeding risk</p> Signup and view all the answers

Which of the following is true regarding anticoagulant use in older adults?

<p>Both UFH and LMWH are equally effective in older persons. (A)</p> Signup and view all the answers

Pharmacotherapy for older patients should consider the pill burden and potential drug-drug interactions.

<p>True (A)</p> Signup and view all the answers

What is one reason for cooperation with experienced pharmacists in the care of older adults?

<p>To optimize pharmacotherapy.</p> Signup and view all the answers

Flashcards

NSTE-ACS in Older Persons

Non-ST elevation acute coronary syndrome particularly in patients aged ≥ 75 years.

Age as a Risk Factor

Age significantly increases the risk of cardiovascular disease and adverse outcomes.

Mortality Rates by Age

Mortality rate increases with age after a first non-STEMI; ranges from 13.3% to 45.5% across age groups 65-90+ years.

Comorbidities in Older Patients

Older patients with NSTE-ACS often have additional health issues like hypertension and heart failure.

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Clinical Presentation in Older Patients

High suspicion needed to diagnose NSTE-ACS in older individuals due to atypical symptoms.

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Troponin elevation in older adults

Troponin levels can be elevated in older patients without acute illnesses.

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99th percentile troponin cut-off

The conventional cut-off for troponin is 0.014 ng/mL.

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Hs-cTnT levels

High-sensitivity cardiac troponin T; mild elevations are common in older adults.

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Independent prognostic marker

Increased hs-cTn levels can predict future cardiac events.

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Need for research in older adults

Older patients are under-represented in studies on coronary artery disease.

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Biological vs. Chronological age

Management decisions should consider a patient's biological age.

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Elevated cTn and cardiac events

Elevations in cTn are linked to future cardiac problems in older women.

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Limited management data

There is a scarcity of clinical trial data for managing older patients.

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Physician Judgment

Decisions regarding patient care primarily based on clinical expertise rather than age metrics.

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Epigenetic Clock

A biological predictor of age based on DNA methylation patterns.

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Telomere Length

Length of protective caps on chromosomes, associated with aging.

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Creatinine Clearance

Measurement used to assess kidney function for appropriate drug dosing.

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Antiplatelet Agents

Medications that prevent blood platelets from clumping, reducing clot risk.

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Clopidogrel

A P2Y12 inhibitor used primarily in older patients to prevent clots.

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Fondaparinux

An anticoagulant recommended for older patients; lower bleeding risk compared to heparin.

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Pill Burden

The total number of medications a patient takes, affecting treatment compliance.

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Study Notes

NSTE-ACS in Special Groups

  • Age: A powerful risk factor for cardiovascular disease (CVD) complications and adverse outcomes after CVD events, procedures, and interventions.
  • Older adults (≥75 years): Represent 24-43% of NSTE-ACS cases and 28% of STEMI admissions.
  • Comorbidities: Older patients with NSTE-ACS are more likely to have conditions like hypertension, heart failure, atrial fibrillation, Transient Ischemic Attack/stroke, anemia, and renal insufficiency.
  • Mortality: Mortality is highest in the oldest old (≥90 years) with a 1-year mortality rate increasing progressively from 13.3% (65-79 years) to 45.5% (≥90 years).

Clinical Presentation

  • Chest pain: Fewer older patients (especially those >85) present with chest pain (40%) compared to younger patients (<65, 77%).
  • Atypical symptoms: Older patients often present with symptoms like dyspnea (49%), diaphoresis (26%), nausea/vomiting (24%), or neurological issues (19%).
  • Acute pulmonary edema: A common presentation in older NSTE-ACS patients.
  • Other illnesses: Type 2 MI is common, associated with tachycardia, pneumonia, sepsis, or bleeding.

Troponin Elevation in Older Patients

  • High troponin levels: Troponin elevations above the 99th percentile upper reference limit (URL) are common in older patients without known acute illness (ACS).
  • Specificity issues: Conventional cut-off values (0.014 ng/mL) have low specificity in older adults.

Management

  • Reduced studies: Fewer studies have been conducted specifically on older adults with CAD. Recommendations are less strong compared to younger counterparts.
  • Biological age vs. chronological age: Management should consider the patient's biological age, not their chronological age.
  • Renal impairment: Older patients frequently have renal impairment, necessitating individualised drug dosages (e.g., adjusted creatinine clearance).
  • Comorbidities and drug burden: Pharmacotherapy must account for potential drug-drug interactions and the patient's life expectancy.

NSTE-ACS in Women

  • Later onset: Women experience CAD approximately a decade later than men, often after menopause.
  • Comorbidities: Women present with higher rates of comorbidities like obesity, diabetes, hypertension, and osteoarthritis.
  • Hospital outcomes: Premenopausal women who experience NSTE-ACS tend to have worse outcomes and higher hospital mortality compared to men of the same age.

NSTE-ACS in Patients with CKD (Chronic Kidney Disease)

  • Diagnosis difficulties: Diagnosis can be challenging due to atypical symptoms and difficulty interpreting cardiac biomarkers.
  • High-sensitivity cardiac troponin (hs-cTn): More helpful in patients with CKD, with hs-cTn tests showing elevated levels in almost all patients with stage 5 CKD.
  • Serial testing: Serial hs-cTn testing over 6-8 hours is recommended for better diagnostic accuracy in suspected ACS.
  • Mortatlity: Patients with more severe CKD (stages) have significantly higher mortality rates.

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