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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    Description

    Explore the impact of age and comorbidities on NSTE-ACS in older adults. This quiz highlights statistical data on presentation, complications, and mortality rates among different age groups, particularly those over 75 years. Test your understanding of how older patients differ from younger ones in clinical settings.

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