To the Editor,
.
We have read with interest the review article by Jackson et al.1 on cardiovascular disease in the elderly. An important conclusion of the article is the lack of scientific support for therapeutic strategies in this population, due to the frequent exclusion of elderly patients from clinical trials. This is a common situation in relation to the different diseases mentioned in the article and, in particular, to myocardial infarction (MI). In the section devoted to this disease, the authors summarize the special features of fibrinolysis (FL) and percutaneous coronary intervention (PCI) in this age group. Following our recent articles on the subject,2, 3 we would like to offer several comments.
First, eligibility for reperfusion therapy crucially depends on the temporal stage of MI at the time of presentation, and the risk of complications at baseline. Both these factors are influenced by age.4, 5 Delays in presentation increase with age due to the decreased perception of pain, cognitive impairments, comorbidities (“distractors”), or social limitations.6 This delay is strikingly longer in community registries (patients 75 years and older) than in clinical trials (4.7h vs 2.1h, respectively).7, 8 However, even in the latter case, advanced age is associated with delayed presentation and an increased risk of complications.8
On the other hand, the authors refer to intracranial hemorrhage (ICH) secondary to FL. Although ICH is a catastrophic event, death from other causes remains the most common adverse event in elderly patients with MI; specifically, there is a high rate of electrical and mechanical complications (eg, free-wall rupture, cardiogenic shock). In an analysis of 706 patients with MI aged 75 years or more, free-wall rupture was more frequent among those treated with FL (17.1%) than in those undergoing PCI (4.9%) and even in those not receiving reperfusion therapy (7.9%).9 In fact, FL could have a deleterious effect on very elderly patients. Thus, the management of these patients remains an open question. Lenderink et al.10 demonstrated the usefulness of a group of variables to predict early mortality, most of which are available at the time of admission. These were used to develop and validate a risk model that was especially calibrated for elderly patients and which was proposed as an additional tool with which to choose the best therapeutic approach. However, the final decision continues to be made individually, taking into account the best outcome as well as the most humane choice regarding a serious disease with frequent and fatal complications. Moreover, the principle of patient autonomy (respect for their preferences) should play a role in our decisions; the patients’ wishes not to undergo invasive procedures are specifically mentioned in the clinical practice guidelines.4, 5
Corresponding author: achevia@gmail.com