Guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) for management of patients with ST-segment elevation MI (81
), and the 2009 update (82
) make no distinction based on age for the assessment and initial management of MI. All patients with ST-segment elevation MI should undergo rapid evaluation for reperfusion therapy and have a reperfusion strategy implemented promptly after contact with the medical system (Level of Evidence: A). Elderly patients appear to have a modest benefit from PCI over fibrinolysis, although the benefit is mainly in recurrent ischemia (17
). This suggests that suitable elderly patients can be offered primary PCI and may benefit from this approach. The class of recommendation for both primary PCI and rescue PCI in patients with cardiogenic shock is Class II in patients over 75 years of age and Class I in younger patients. This is mainly because younger patients demonstrated clear benefit in the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial (84
), whereas older patient data are based on registries (18
). When PCI is not available and fibrinolysis is the treatment of choice for reperfusion, elderly patients have improved outcomes when treated with fibrinolytic agents compared with placebo (10
), but this benefit may not extend beyond 85 years of age.
The guidelines for standard adjunctive therapies during the index admission, such as aspirin, beta-blockers, and antiplatelet agents, make no differential recommendations based on age. However, the addition of prasugrel in the 2009 update comes with a Federal Drug Administration warning about use in those 75 years of age or older, because of lack of benefit and increased risk of intracranial hemorrhage in this age group (85
). In addition, low molecular weight heparin should not be used as an alternative to unfractionated heparin in combination with fibrinolytic therapy in patients over 75 years of age.
After reperfusion of MI, therapies to prevent and treat LV remodeling include beta-blockers, ACE inhibitors, aldosterone antagonists, and cardiac rehabilitation. In the ACC/AHA guidelines, these are recommended for all, with no stipulation on age. Aspirin, ACE inhibitors, beta-blockers, and statins appear to be at least as effective in elderly patients as in younger patients following MI (12
). In summary, with the exception of prasugrel and low molecular weight heparin after fibrinolysis, elderly patients should be considered for the same therapies as young patients in the setting of acute MI and for prevention of long-term adverse LV remodeling.