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Archives of cardiovascular diseases
Volume 103, n° 1
pages 1-2 (janvier 2010)
Doi : 10.1016/j.acvd.2009.11.003
Received : 5 November 2009 ; 
Elderly patient with coronary heart disease: Time for appraisal
Le patient coronarien âgé : le temps de l’évaluation
 

Olivier Hanon
Geriatrics department, Paris Decartes University, Broca Hospital, 54–56, rue Pascal, 75013 Paris, France 


Mots clés : Sujet âgés, Fragilité, Coronaropathie, Évaluation gériatrique, Recommandations

Keywords : Elderly, Frailty, Coronary heart disease, Geriatric assessment, Guidelines


Life expectancy in France is increasing by about 3 months each year. It is currently 80.5 years (84.5 years for women and 77.6 years for men). This development appears all the more pronounced since it involves the oldest populations, and will result in the number of octogenarians in the world growing from 69 million in 2000 to 379 million by 2050 [1].

Because of this ageing of the population, the incidence and prevalence of coronary artery disease are rising significantly. The clinical presentation of coronary artery disease is even less typical, and the prognosis darker, since it emerges in frail patients with multiple pathologies. Hence, caring for elderly patients with coronary artery disease requires not only cardiological skills, but also a geriatric assessment making it possible to detect the ‘factors of frailty’ that will have a major impact on prognosis, such as cognitive disorders, functional decline, kidney failure, depression, undernourishment, falls and social isolation [2, 3].

The article by Huerre et al. [4] highlights the important role that functional decline plays in the prognosis for patients over 70 years of age who are hospitalized for acute coronary syndromes. Within this population, functional decline is evaluated using a scale that assesses Activities of Daily Living [5], such as bodily hygiene, ability to go to the toilet, locomotion, continence or independence during meals, and is associated with an increased risk of death (hazard ratio 2.77, 95% confidence interval 0.99–7.72) during a median follow-up of 447 (271–524) days. These elements indicate the importance of global assessment of the elderly patient with coronary artery disease. This approach, which is often difficult to perform completely in an emergency situation, should be completed during a period of stability, if needed, by a specialized team. It assesses medical and psychosocial elements and, through the use of simple tests, provides fast detection of associated pathologies, an evaluation of the patient’s dependency and his/her social situation. These elements have been recognized by a group of experts from the French Cardiology Society (Société française de cardiologie [SFC]) as well as the French Society of Geriatrics and Gerontology (Société française de gériatrie et gérontologie [SFGG]) who, in this issue of Archives of Cardiovascular Diseases , have published a national consensus on the characteristics of ‘management of coronary artery disease in older adults’ [6].

Although the care strategy is fundamentally the same in octogenarians as in younger patients, a clear under-utilization of recommended treatments has been observed in elderly persons with coronary artery disease [7] – a population that is likely to receive greater benefit from them due to its high cardiovascular risk. Although use of the treatments requires particular precautions due to comorbidities and pharmacokinetic or pharmacodynamic changes linked to ageing, real contraindications against betablockers, angiotensin converting enzyme inhibitors, antiplatelet agents or statins are rare in octogenarians. Lastly, at this age, the option of myocardial revascularization is essentially posed in acute situations and is dependent upon clinical and severity criteria, as well as the presence of comorbidities that make it possible to evaluate the risk/benefit ratio.

In summary, optimal care for elderly patients with coronary artery disease is the result of the close collaboration between cardiologists, geriatricians and attending physicians. Such a multidisciplinary approach may reduce mortality and institutionalization in frail elderly patients [8].

Conflicts of interest

The authors have no conflict of interest to declare


 Functional decline in elderly patients presenting with acute coronary syndromes: Impact on midterm outcome, C. Huerre, A. Guiota, S. Maréchaux, J.-L. Auffray, J.-J. Bauchart, D. Montaigne, F. Mouquet, M. Lesenne, F. Puisieux, P. Goldstein, P. Asseman, P.-V. Ennezat, doi:10.1016/j.acvd.2009.09.005.

References

United Nations Department of Economic and Social Affairs. World Population Ageing 1950–2050, Population Div., DESA, United Nations. Date accessed 6 November 2009. worldageing19502050/.
Corti M.C., Salive M.E., Guralnik J.M. Serum albumin and physical function as predictors of coronary heart disease mortality and incidence in older persons J Clin Epidemiol 1996 ;  49 : 519-526 [cross-ref]
Krumholz H.M., Chen J., Chen Y.T., and al. Predicting one-year mortality among elderly survivors of hospitalization for an acute myocardial infarction: results from the Cooperative Cardiovascular Project J Am Coll Cardiol 2001 ;  38 : 453-459 [cross-ref]
Huerre C, et al. Functional decline in elderly patients presenting with acute coronary syndromes: impact on midterm outcome. Arch Cardiovasc Dis 2009; this issue.
Katz S., Ford A.B., Moskowitz R.W., and al. Studies of illness in the aged. The index of Adl: A standardized measure of biological and psychosocial function JAMA 1963 ;  185 : 914-919
Hanon O, et al. Consensus of the French Society of Gerontology and Geriatrics and the French Society of Cardiology for the management of coronary artery disease in older adults. Arch Cardiovasc Dis 2009;102:829–45.
Avezum A., Makdisse M., Spencer F., and al. Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE) Am Heart J 2005 ;  149 : 67-73 [cross-ref]
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