Evaluating current and emerging antithrombotic therapy currently available for the treatment of acute coronary syndrome in geriatric populations

ABSTRACT

Introduction: Acute coronary syndromes (ACS) represent one of the most perilous presentations of ischemic heart disease. Temporal trends clearly demonstrate that ACS occur later and later in life. Elderly patients with ACS comprise a populous and growing group, with more than half of individuals presenting with myocardial infarction being 75 years or older. Nevertheless, geriatric patients are greatly underrepresented in the landmark ACS trials evaluating innovative pharmacological strategies.

Areas covered: The authors critically summarize recently published research on contemporary and emerging antithrombotic therapy for the treatment of ACS in geriatric patients.

Expert opinion: Elderly ACS patients are characterized by simultaneously increased risk of cardiovascular events and bleeding. Very few studies assessing the efficacy and safety of novel ACS pharmacotherapy in geriatric patients are currently available. Guidelines on the treatment of ACS are based on the overall results of major randomized clinical trials (RCTs), and data supporting the recommended therapy in elderly mainly derive from subanalyses of these RCTs. Properly designed and powered RCTs are necessary to properly evaluate the net effect of current and emerging pharmacotherapy in geriatric patients. Until such data are available, elderly ACS patients should receive treatment according to the general recommendations.

KEYWORDS:

• Antiplatelet therapy
• cangrelor
• elderly
• myocardial infarction
• P2Y12 receptor antagonists
• prasugrel
• rivaroxaban
• ticagrelor

Article highlights

• Temporal trends clearly demonstrate that acute coronary syndromes (ACS) occur later and later in life, with more than half of acute myocardial infarction cases occurring in patients aged 75 years or older.

• Geriatric patients with ACS differ from their younger counterparts, including higher prevalence of comorbidities, frailty, atypical ACS presentation, and increased risk of cardiovascular events and bleeding.

• Majority of available data regarding ACS treatment in this population origin from subanalyses of landmark randomized trials or from non-randomized studies.

• Newly published research on use of different P2Y12 receptor antagonists do not provide clear answers regarding the choice of antiplatelet therapy in geriatric patients.

• Immediate design of large-scale randomized trials to explore the net influence of modern pharmacotherapy on clinical outcome in elderly ACS patients is warranted.

This box summarizes key points contained in the article.

Declaration of interest

J Kubica has received consultancy fees from AstraZeneca while P Adamski has received lecture fees from AstraZeneca. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This manuscript was not funded.