Acute coronary syndrome (ACS) in elderly patients More comorbidities, thrombosis and increased risk. Underrepresented in prospective studies and randomized clinical trials, it is challenging to manage. Recently, a review published in the European Heart Journal summarized evidence-based treatment of elderly patients based on available data.
Assessment and management of elderly patients with ACS >
Risks and Benefits of Revascularization in Elderly ACS Patients
Aging increases the cardiovascular burden and affects the entire cardiovascular system, as shown in Figure 2. 
Figure 2 Changes in pathophysiological pathways in elderly patients and inflammatory dysregulation are hallmarks of cardiovascular aging, which can increase the risk of thrombotic events. At the same time, aging is also a major risk factor for bleeding. In addition, many elderly patients with ACS have multiple comorbidities, including chronic kidney disease, myocardial fibrosis and hypertrophy, valvular disease, and frailty, which make the management of elderly patients with ACS more difficult. A consensus document published by the Bleeding Academic Research Consortium (BARC) states that among patients undergoing percutaneous coronary intervention (PCI), >75 years of age are Criteria for high bleeding risk, patients had an expected BARC grade 3 or 5 bleeding rate of <4% at 1 year. However, recent efficacy studies have shown that the incidence of BARC grade 3 or 5 bleeding risk in elderly patients may be >4%, and it is recommended that advanced age be a primary rather than a secondary criterion. More importantly, the bleeding risk appeared to increase linearly with age. 1. ST-segment elevation myocardial infarction (STEMI) span>Elderly patients have a higher risk of major bleeding (especially intracranial hemorrhage) during thrombolytic therapy, and primary PCI is the first choice for patients with indications. The 2017 ESC STEMI Guidelines pointed out that there is no upper age limit for reperfusion therapy, especially for primary PCI. However, higher comorbidity rates are still associated with lower coronary catheterization and PCI success rates in older patients. 2. Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) The 2021 ESC NSTE-ACS Guidelines recommend that elderly patients use the same diagnostic and intervention strategies as younger patients (I, B), based on ischemia and bleeding risk, life expectancy, complications Individualized treatment based on symptoms, non-cardiac surgery, quality of life, frailty, cognitive function, and patient values and preferences. 3. Treatment of acute myocardial infarction associated cardiogenic shock (AMICS) Prompt myocardial revascularization is the only measure that reduces mortality from AMICS, but the SHOCK trial does not appear to have any benefit in older patients. Considering the high incidence of frailty and comorbidities in elderly patients (especially those with previous renal dysfunction), it is recommended that elderly AMICS patients only undergo culprit vessel revascularization. 4. Gender Differences women’s risk of ACS Increases with age, but women have a lower risk of ACS than men before age 90. Prospective studies have shown that the risk of coronary atherosclerosis is delayed by approximately 10 years in women compared with men, and this gap persists decades after menopause. In addition, there are gender differences in care and outcomes among patients with ACS that vary by age. Among younger patients, women with ACS have a lower incidence but higher mortality than men (for reasons not yet known). In-hospital and long-term mortality remained higher in women with STEMI than in men after adjusting for confounders; gender differences in outcomes were smaller among patients with NSTEMI. These differences may be attributable to increasing age, higher comorbidity burden in women, and lower rates of revascularization. 5. Clinical complexity and comorbidity management During the aging process, patient It is influenced by a variety of factors, including disorders that affect daily life, such as frailty, multiple comorbidities, disability, and cognitive impairment (Table 1). Table 1 Geriatric syndromes 
Chronic renal insufficiency is one of the most common and important independent predictors of cardiovascular death. Diseases that increase myocardial fibrosis and cardiac hypertrophy (leading to left ventricular dilatation and systolic dysfunction), and peripheral vascular disease (associated with promoting vascular calcification) are associated with increased mortality. Unlike comorbidities, frailty is often associated with the onset/development of chronic disease. Some frailty-related scores can provide useful clinical and prognostic information in older patients. In addition, some elderly patients have cognitive impairment. Data show that patients with cognitive impairment are more likely to have serious cardiovascular events and recurrence of myocardial infarction. In addition to guideline-directed medication for acute event management in these patients, treatment of modifiable risk factors is also critical to prevent recurrence. Although debilitated patients have a higher risk of bleeding and death, PCI can benefit patients. Any strategy related to PCI should be individualized.
Antithrombotic strategies in secondary prevention
Figure 3 Optimal management of elderly ACS< >1. Dual antiplatelet therapy (DAPT) Antiplatelet therapy is the cornerstone of antithrombotic therapy for ACS. However, in elderly patients with ACS, which P2Y12 receptor (+aspirin) should be used to provide the best DAPT therapy remains controversial. The “2021 NSTE-ACS ESC Guidelines” pointed out that except for patients with high bleeding risk, it is recommended to use a strong P2Y12 receptor inhibitor for 12 months of DAPT treatment. High-risk patients can be treated with aspirin plus clopidogrel for 3 months (1 month in patients with very high bleeding risk), followed by monotherapy. In clinical practice, the ARC criteria or the PRECISE-DAPT score (≥25 points indicating high bleeding risk) can be used to assess the bleeding risk of patients. In general, most elderly patients with ACS should be treated with short-term DAPT (3-6 months), preferably clopidogrel combined with low-dose aspirin. It is worth noting that for clinicians, individualized assessment of elderly patients based on bleeding risk and ischemic risk appears to be the most reasonable choice of DAPT agent and duration. Methods. 2. Antiplatelet + Anticoagulation For elderly patients with AF and ACS, dual therapy (oral anticoagulant + single-agent antiplatelet therapy) is generally safer than triple therapy (oral anticoagulant + DAPT) without serious ischemic cardiac events and/or cerebrovascular adverse events. Novel oral anticoagulants (NOACs) should be preferred when choosing an anticoagulant. After the completion of dual antithrombotic therapy, lifelong direct oral anticoagulant monotherapy is recommended, except for clinical factors and/or procedures that increase the risk of ischemia. 3. Other Secondary Prevention Strategies Elderly Atherosclerosis risk factors are prevalent in ACS patients, and the burden of comorbidities is high. Lifestyle changes are essential to improve blood pressure control and achieve blood sugar and cholesterol goals. Strengthening physical activity is an important part of secondary prevention in elderly patients, but given the poor physical condition of patients, it is recommended to develop an individualized exercise program. The clinical benefit of elderly patients in the use of drugs for secondary prevention is controversial. Overall, clinicians are advised to prescribe medications for older patients with ACS according to relevant guidelines for younger patients. Recommended drug treatments for ACS include beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptors (ARBs), and aldosterone antagonists. During the course of medication, the serum potassium level and renal function of elderly patients should be monitored regularly. With regard to lipid-lowering therapy, despite the reduction in life expectancy in older patients, the standard of care for cholesterol should not be lowered. All ACS patients without contraindications, regardless of cholesterol level, should start statin therapy as soon as possible. Yimaitong compiled from: Nuccia Morici, Stefano De Servi, Leonardo De Luca, et al. Management of acute coronary syndromes in older adults. European Heart Journal (2022) 43 , 1542–1553.