Elderly Patients With Acute Coronary Syndromes: Higher Risk and Greater Benefit From Antiplatelet Therapy and/or Interventional Therapy

Outcomes in elderly patients with acute coronary syndromes are worse than in younger patients, and disappointingly, some therapies, such as thrombolysis for ST elevation myocardial infarction, appear to have less relative benefit than in younger patients. However, in unstable angina and non-ST elevation myocardial infarction, the elderly appear to derive greater relative and absolute benefit from the newer more potent antithrombotic therapies. With the glycoprotein IIb/IIIa inhibitors, an equivalent relative benefit has been observed, which translated into a greater absolute benefit in older vs. younger patients. Similarly, when comparing clopidogrel plus aspirin to aspirin alone, there was a consistent 20% reduction in cardiovascular death, myocardial infarction, or stroke in both elderly and younger patients. An emerging area of focus, however, is that of the appropriate dose in the elderly. Because the elderly on average have worse renal function, many drugs will not be cleared as well, and thus higher plasma levels will exist, which can translate into higher bleeding complications. Future studies are evaluating downward dose-adjustment of new therapies in the elderly as a means of improving the efficacy/safety profile. Thus, in unstable angina and non-ST elevation myocardial infarction, elderly patients are at higher risk and appear to derive particular benefit from more aggressive antithrombotic and interventional therapies.