Management Of Non-St Elevation Myocardial Infarction (NSTE-ACS) PDF 2021

CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS)...

CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 8. NSTE-ACS IN SPECIAL GROUPS 8.1 NSTE-ACS in Older Persons Age is a powerful risk factor for CVD and also an independent risk factor for adverse outcomes after CVD events, for complications after cardiovascular procedures and interventions, and for side effects of pharmacotherapy.277 International registries show that 32% to 43% of NSTE-ACS, and about 24% - 28% of STEMI admissions were for patients aged ≥ 75 years.278,279 These older persons with NSTE-ACS are more likely to be women, have lower body mass indices, higher prevalence of such comorbidities as hypertension, heart failure, atrial fibrillation, Transient Ischemic Attack/stroke, anemia and renal insufficency.280,281 The mortality rate after a first non-STEMI in the oldest old patients is highest: with respect to 1-year outcomes, among patients who were 65 - 79, 80 - 84, 85 - 89, and at least 90 years old, mortality increased progressively from 13.3% to 23.6%, 33.6%, and 45.5%, respectively.282 8.1.1 Clinical Presentation A high index of suspicion is necessary to make a diagnosis of NSTE-ACS in older patients. Only 40% of those aged >85 years had chest pain on presentation compared with 77% of those aged 99th percentile URL in older patients presenting without ACS or other acute illnesses known to cause to troponin elevation.284,285 In one study almost 40% of patients aged > 70years had elevated troponins.285 The conventional cut-off value (99th percentile: 0.014 ng/mL) provided low specificity, particularly in older adults.286 80 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 The observed increased hs-cTn levels is associated with the presence of pre-existing comorbidities which are independent of the effects of age.287 Mild elevations of hs-cTnT levels are common in older patients, and increased hs-cTn levels are an independent prognostic marker in this population.288,289 Elevations in cTn were independently associated with future cardiac events in older women without apparent clinical manifestations.290 A different hs-cTnT cut-off may be required for patients older than 70 years but this is currently undefined.286-289 8.1.2. Management Comparatively fewer studies have been conducted in older adults - specifically older persons are under-represented in many studies on CAD. Therefore, the strength of recommendations for this age group is somewhat lower than that supporting recommendations in younger adults, highlighting the dire need to conduct more research studies in this patient population. There is limited trial data to guide management in the older person especially in the setting of advanced age (more than 75 years) or significant comorbidity (e.g. prior stroke, renal impairment). One should consider the biological age rather than the chronological age of the patient when making management decisions. This is almost always based on physician judgement rather than on biological age predictors. There are several existing predictors which are still in the research stage - the most plausible candidates being the epigenetic clock and telomere length.291 Older patients are a heterogenous group and the risk benefit ratio of each intervention should be individualised. As renal impairment is very common in older adults, creatinine clearance should be calculated to enable appropriate drug dosing (Appendix XIV, page 105). Pharmacotherapy should also take into account the older person’s pill burden, potential drug-drug interactions and the older person’s life expectancy. Cooperation with experienced pharmacists is therefore desirable to optimise pharmacotherapy. 8.1.2.1 Pharmacotherapy  Antiplatelet Agents I,A  Both aspirin and clopidogrel (especially in those undergoing PCI) confer greater benefits in older adults.279,292 I,B  Clopidogrel is the P2Y12 inhibitor of choice in older persons > 75 years.293  Prasugrel may be used in patients older than 75 years at the reduced IIa,B dose of 5mg.294,295 81 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021  Anticoagulants I,A  Both UFH and LMWH are equally effective in older persons. 293,296 However bleeding risk is high with both agents. A reduced dose of 0.75-1.0mg/kg twice daily should be used in patients aged ≥75 years.293 I,B  Fondaparinux is recommended in older NSTE-ACS patients and those with STEMI who are not undergoing primary PCI. Fondaparinux is associated with less bleeding than heparin and is as efficacious.  Others: I,A  A high-dose statin regimen provides greater protection against death or MACE than a low-or moderate-dose statin regimen in older persons.297,298 8.1.2.2 Revascularization  Older patients have greater in-hospital and long-term benefits with an IIa,B early invasive strategy.299-301 However, there is an increased risk of major bleeding.  When selecting patients for an early invasive strategy, the risk benefit I,C ratio must be considered. Most older patients with NSTE-ACS have multivessel disease for which CABG is more suitable than PCI. Patient preferences and frailty are important considerations in decision making. In addition, duration of hospitalization and post-surgery convalescence may be prolonged in older patients after CABG and, therefore, should be considered in counselling the patient.  For patients with multi vessel disease and not suitable for CABG, partial revascularization of the culprit lesion may be a consideration. 8.1.2.3 Cardiac Rehabilitation  Observational studies show that older patients have as much benefit as IIa,B younger patients with cardiac rehabilitation after an ACS.302,303 8.2 NSTE-ACS in Women Women develop CAD about a decade later than men (after menopause) and at that age have more comorbidities such as obesity, diabetes, hypertension and osteoarthritis.304,305 However, with the use of evidence-based treatment, women have the same survival as men.306 Premenopausal women who develop NSTE-ACS however, have a higher in-hospital mortality and worse long term outcomes than men of the same age.304 82 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 8.2.1 Clinical Presentation Women presenting with ACS often have atypical symptoms such as neck and shoulder ache and dyspnea. Often, women have non-specific ECG changes such as T wave changes even in the absence of heart disease, thus making the diagnosis of CAD difficult. 8.2.2 Management Women with NSTE-ACS: I,B  should be managed with the same pharmacological therapy as that for men for acute care and for secondary prevention, with attention to weight and/or renally calculated doses of antiplatelet and anticoagulant agents to reduce bleeding risk304, 307-311 I,A  and high-risk features (ie, troponin positive) should undergo an early invasive strategy149,312,313 III,B  and low-risk features and troponin negative should not undergo early invasive treatment because of the lack of benefit149,312 and the possibility of harm.149 8.3 NSTE-ACS in Chronic Kidney Disease (CKD) In patients with ACS, the presence of CKD is an additional high-risk feature associated with increased mortality. The more severe the CKD, the higher the mortality.314-316 8.3.1 Diagnosis The diagnosis of ACS in patients with CKD is often difficult though essential.  Traditional diagnostic tools such as symptoms and ECG’s are not always helpful.  The interpretation of cardiac biomarkers may also be difficult.  cTn are increased in patients with CKD in the absence of clinical myocardial ischemia, making their interpretation problematic.317  While older cTn tests had a false-positive rate of 30% to 85% in patients with stage 5 CKD, the hs-cTn tests display elevated levels in almost 100% of these patients.62,317  In suspected ACS, it is important to do serial testing of cTn over 6-8 hours rather than to rely on a single test result.318  A distinct rise and fall in the levels over baseline correlated with clinical suspicion of an ACS (new ischemic ECG changes or new regional wall motion abnormalities on echocardiography), strongly support the diagnosis of MI.318,319 A rise and/or fall is cTn may also occur in acute volume overload and congestive heart failure.10  Studies have shown that chronically elevated cTn levels is predictive of increased risk of mortality and cardiovascular events.320-322 83 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 8.3.2 Management Patients with renal impairment were excluded from most clinical trials. In general, the management of patients with CKD is similar to those with normal renal function except for the following differences:  Patients with CKD have more co-morbidity and are usually older.314  They are at increased bleeding risks. The doses of antithrombotic agents need to be adjusted accordingly to avoid excessive bleeding (Appendix VII, page 99).323  Medications:  Antiplatelet agents - Although DAPT has become the standard of care in patients with ACS and normal renal function, the benefits in persons with CKD are uncertain and are potentially outweighed by bleeding hazards.323,324 In these patients, treatment should be individualised.  Anticoagulants - Heparin (both UFH and LMWH) are widely used in ACS. The bleeding risk of these agents however increases with the increasing severity of baseline renal insufficiency.323 Dose adjustments are important. (Appendix IX, page 101)  Fondaparinux is contraindicated in severe renal failure (CrCl