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With improving life expectancy in developed countries, the proportion of people aged >65 years will significantly increase over the next 20 years, and the prevalence of those >85 years of age will almost double. Importantly, increasing age is among the major predictors of adverse events in patients with coronary artery disease (CAD), with elderly patients showing higher in-hospital mortality and periprocedural complication rates as compared with younger individuals. However, elderly patients are less likely to receive evidence-based therapies for CAD, particularly referral to cardiac catheterization and coronary revascularisation. In the setting of acute coronary syndromes (ACS) the expected benefit from an early invasive approach has been demonstrated to be similar across different age categories; however, elderly patients are still frequently managed conservatively because of a systematic overestimation of periprocedural complications and underestimation of the risk of spontaneous adverse events. These conditions are particularly evident in the setting of non-ST-segment elevation ACS (NSTEACS), which represent the most frequent type of ACS among elderly patients, frequently characterised by atypical symptoms, challenging comorbidities (ie, atrial fibrillation, pulmonary disease, peripheral vascular disease), and extensive CAD burden.
Despite registries confirming the high prevalence of NSTEACS among elderly patients, this patient subset is typically under-represented in randomised controlled trials (RCTs) that generally favour the inclusion of younger and relatively less comorbid patients. Accordingly, despite current NSTEACS guidelines recommending a routine invasive approach for the majority of patients irrespective of age, the opportunity of early coronary angiography and revascularisation in the elderly is still disputed, due to scarce and …