By Stefano Savonitto
Older patients with ST-elevation myocardial infarction (STEMI) should not be managed any differently from younger STEMI patients, but age-related pharmacokinetic changes and a predisposition to certain complications need to be taken into account when managing these patients. Stefano Savonitto (director, Cardiology Division, Arcispedale S Maria Nuova, Reggio Emilia, Italy) talked to Cardiovascular News about treating older patients with STEMI. He spoke about this topic at JIM (Joint Interventional Meeting; 14–15 February 2013, Rome, Italy).
What do the latest STEMI guidelines say about the management of STEMI in older patients and how do they compare with previous guidelines?
They say very little—the 2013 American College of Cardiology Foundation/the American Heart Association guidelines (O’Gara et al. Journal of the American College of Cardiology 2013; 61: epub) give no specific recommendations with regard to elderly patients. However, the 2012 European Society of Cardiology (ESC) guidelines (Steg et al. Eur Heart J 2012; 33:2569–619) do state that elderly patients may have atypical symptoms and, therefore, a high level of suspicion should be exerted in the case of possible ischaemic symptoms. They also advise that doctors should be very careful when using antithrombotic agents in older patients because of the risk of overdosing with drugs and the ensuing increased risk of bleeding complications. No other recommendations are made, meaning that treatment strategies in older patients with STEMI should not differ from treatment strategies in younger patients—and I agree with this approach.
The evidence base for older patients can be sometimes limited due to the relative lack of “old” (65 plus) or “very old” (75 plus) patients recruited to randomised controlled trials. Is this the case with STEMI?
Yes, that is exactly the case with STEMI. As I discussed in my presentation at JIM, a meta-analysis by Héctor Bueno showed the low number of older patients in modern STEMI studies (Bueno. European Heart Journal 2011; 32: 51–6). We definitely need specific trials for the management of STEMI in older patients. Also as mentioned in my talk at JIM, We have completed the first trial of older patients with non-ST elevation acute coronary syndromes (NSTEACS) and this was the Italian Elderly ACS trial (Savonitto et al. JACC Cardiovasc Interv 2012; 5: 906–16). We are now enrolling patients in the Elderly ACS 2 trial, which will include both STEMI and NSTEACS patients undergoing early percutaneous coronary intervention (PCI).
What does the evidence base indicate is the optimum management of older patients with STEMI?
Although the evidence is not as numerically solid as one would desire, I think the evidence supports the superiority of primary PCI with respect to thrombolytic therapy; supports a moderate use of antithrombotic agents with possible preference for the use of bivalirudin (Angiox ,The Medicines Company) over unfractionated heparin during PCI; and supports the systematic use of the radial angiographic approach.
How might an older patient respond differently from a younger patient to the pharmacological treatments for STEMI due to the pharmacokinetic changes that occur with age?
It is not just pharmacokinetics that needs to be considered in older patients, but also a predisposition to bleeding (both acutely and during follow-up) and renal failure. A recent finding is the observation of reduced response of the elderly to clopidogrel (Plavix, Bristol-Myers Squibb and Sanofi Aventis) with higher on-treatment platelet reactivity. We are currently investigating alternative pharmacological approaches.
Please can you expand on the main complications to be aware of when managing older patients with STEMI?
The most common are bleeding and (mostly) transient renal failure, but there are also vascular complications. Some of the classical complications, such as septal and free wall ruptures seem to be reduced with primary PCI. Post-acute mitral insufficiency remains an issue, particularly after infero-posterior myocardial infarction.
In your practice, how do you treat older patients with STEMI?
At my centre, we treat older patients exactly we would treat younger patients. We do primary PCI, mostly using the transradial approach. We frequently use bivalirudin rather than unfractionated heparin and glycoprotein IIb/IIIa inhibitors. We tend to avoid the use of drug-eluting stents in order to reduce the duration of dual antiplatelet therapy.