Volume 187 - Issue 8
Discordance between level of risk and intensity of evidence-based treatment in patients with acute coronary syndromes
Author: Ian A Scott
Med J Aust 2007; 187 (8): 479. || doi: 10.5694/j.1326-5377.2007.tb01378.x
Published online: 15 October 2007
Published online: 15 October 2007
In reply: Jelinek rightly draws attention to the need, when caring for patients with acute coronary syndromes, to distinguish disease-related risk from age-related risk arising from frailty, comorbidity, physical disability, cognitive impairment, depression, social isolation, age–treatment interactions, and quality of life. All these factors affect treatment goals in older patients and may, as we conceded, justify withholding certain treatments in individual cases. However, even after accounting for “wise compassion”, under-treatment is still likely because:
our treatment eligibility criteria excluded patients with advanced comorbidity or who declined treatment;
population-based studies of risk–benefit trade-offs argue for more intense treatment use in patients ≥ 75 years,1,2 in whom absolute risk reductions exceed those in younger patients by as much as 10%;3 and
all four key treatments at discharge (aspirin, β-blocker, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and statins) can be administered as once-daily, single tablet formulations, which are usually well tolerated.
Given that a third of patients presenting with acute coronary syndromes are aged 75 years or older, for whom 30-day risk of death or myocardial infarction exceeds 20% and who account for 60% of all deaths related to myocardial infarction,4 we recommend, similar to expert bodies,4,5 judicious (not mantra-driven) use of evidence-based treatments in all eligible older patients.
References
- Alter DA, Manuel DG, Gunraj N, et al. Age, risk–benefit trade-offs, and the projected effects of evidence-based therapies. Am J Med 2004; 116: 540-545.
- Alexander KP, Peterson ED. Treatment of non-ST-elevation acute coronary syndrome in the elderly: current practice and future opportunities. Am J Geriatr Cardiol 2006; 15: 42-49. 0_pgfId-1437344
- Bach RG, Cannon CP, Weintraub WS, et al. The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndrome. Ann Intern Med 2004; 141: 186-195. 0_CBBCJFEB
- Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007; 115: 2549-2569. 0_CBBIFDFC
- Alexander KP, Newby LK, Armstrong PW, et al. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007; 115: 2570-2589. 0_i1091831
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