Top Things to Know: Management of ACS in the Older Adult Population

Published: December 12, 2022

  1. Coronary artery disease (CAD) and acute coronary syndrome (ACS) disproportionately affect older adults over 75 yrs old. This is significant because older adults have both greater comorbidity burden and greater complexity of coronary artery disease.
  2. Physiologic changes that occur with aging result in increased frequency and distinct phenotypes of ACS presentation in this population. With aging, arterial afterload increases coupled with increased myocardial stiffness leading to diastolic dysfunction and increased myocardial demand. Decreased nitric oxide synthase activity leads to impaired coronary endothelial function.
  3. Geriatric syndromes which include multimorbidity with resultant polypharmacy, frailty, cognitive impairment, and delirium have increased prevalence with increasing age and complicate the presentation, assessment, and management of ACS and are associated with worsened outcomes from acute coronary syndromes.
  4. Assessment of ACS in older adults necessitates careful history and physical with adjunctive use of ECG, cardiac biomarkers, and imaging. The interpretation of diagnostic testing is influenced by concurrent comorbidities and physiologic changes associated with aging.
  5. Due to changes in metabolism and dosing weight, dose adjustments in antiplatelet and anticoagulant therapy may be necessary for older patients especially given the increased risk of bleeding in this population which may alter the risk benefits of more potent antiplatelet therapies.
  6. Concurrent atrial fibrillation frequently complicates ACS presentations in older patients who are both at increased risk of thrombotic and hemorrhagic events.
  7. Subgroup analyses of older adults in randomized trials comparing PCI to fibrinolysis for ST-elevation myocardial infarction (STEMI) have supported the safety and effectiveness of PCI in older adults presenting with STEMI.
  8. Randomized trials of invasive compared to conservative therapy in older adults with non-ST elevation myocardial infarction (NSTEMI) have not shown a mortality benefit to an early invasive strategy. However, these trials have been underpowered for clinically significant differences in mortality. Meta-analyses of existing data suggest a benefit regarding ischemic outcomes at the expense of increased bleeding. Risk stratification in this population is less precise and benefits are more heterogenous leading to difficulty discerning who is most likely to derive benefit.
  9. Surgical revascularization offers benefits in patients with high anatomic complexity and CAD which is commonly seen in older adults. Advances in surgical technique have allowed improvements in operative mortality in older adults despite increasing comorbidity.
  10. In patients presenting with cardiogenic shock, treatment of the culprit lesion remains the guideline recommendation. The use of mechanical circulatory support devices is not supported by randomized evidence in any population and the risk of futility is high in the older population.
  11. Transition from the acute setting to the outpatient setting after an ACS presentation is particularly important in geriatric patients who are vulnerable to progressive frailty, decline, and complications during these transitions. Multidisciplinary team approaches including an outpatient cardiologist, primary care clinician, geriatrician, and cardiac rehabilitation referral can improve post discharge functional status and outcomes.


Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL, DeVon HA, Alexander KP; on behalf of the American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology, Council on Lifestyle and Cardiometabolic Health, and Council on Cardiovascular Radiology and Intervention. Management of acute coronary syndrome in the older adult population: a scientific statement from the American Heart Association [published ahead of print December 12, 2022]. Circulation. doi: 10.1161/CIR.0000000000001112