Acute coronary syndrome and angina in older people
THE CONTEXT
Acute coronary syndrome includes unstable angina and myocardial infarction. Recognition of myocardial injury, adverse risk markers and age-related presentations guides assessment.
Definitions and presentation
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Acute coronary syndrome encompasses unstable angina and myocardial infarction.
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Unstable angina consists of new-onset or rapidly worsening angina, angina on minimal exertion or angina at rest, without myocardial injury.
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Myocardial infarction differs from unstable angina by the occurrence of myocardial necrosis. It is diagnosed when myocardial injury occurs with clinical evidence of acute myocardial ischaemia.
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Acute coronary syndrome may occur without a previous history of heart disease or against a background of chronic stable angina.
Prognosis and risk assessment
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Approximately 12% of patients die within one month and 20% within six months of the index acute coronary syndrome event.
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Adverse risk markers include recurrent ischaemia, extensive ECG changes at rest or during pain, raised plasma troponin I or T, arrhythmias and haemodynamic complications during ischaemia.
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Haemodynamic complications include hypotension and mitral regurgitation.
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Careful assessment and risk stratification guide more complex pharmacological and interventional treatments that can improve outcomes.
Angina in older people
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Coronary artery disease becomes more frequent with age and affects older women almost as often as older men.
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Anaemia and thyroid disease are common comorbidities that may worsen angina. Calcific aortic stenosis is common and should be sought in older people with angina.
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Age-related changes in myocardial compliance and diastolic relaxation may cause ischaemia to present with heart failure symptoms such as breathlessness instead of chest discomfort.
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Angioplasty and coronary artery bypass surgery provide symptom relief but carry increased procedure-related morbidity and mortality.
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Outcomes depend on the number of diseased vessels, severity of cardiac dysfunction and number of concomitant diseases as much as on age itself.