Older patients with heart attacks should have the same treatment as younger ones

In the field of cardiology, we have developed some amazing treatments: this includes both procedures and medications that can improve patients’ wellbeing and prolong their lives. However, as we get older, the risks posed by treatments and adverse side effects to drugs increases. With our elderly patients, it becomes much more difficult to balance the benefits offered by certain treatments with the risks that they present.

An example of this is in the treatment of patients coming to hospital with heart attacks. For patients suffering from an STEMI (ST-Elevation Myocardial Infarction) heart attack, which occurs when one of the blood vessels (coronary arteries) connected to the heart is blocked, usually by a blood clot, it is generally accepted that the best treatment for patients of any age is to perform a coronary angiogram. This involves putting a small plastic tube in either the arm or leg and then passing a long tube through to the heart, into which dye can be injected. This allows us to visualise the blood vessels going to the heart. If a vessel is blocked, the same plastic tube can be used to pass a balloon into the blocked artery, which can then be inflated to open the vessel. This is called a coronary angioplasty. A stent (metal scaffolding) is often then expanded to keep the blood vessel open.

This treatment and other improvements, such as medication changes, have meant that the death rate of patients attending our hospitals with STEMI heart attacks has decreased from about 15% to 5% over the last 30 years. Patients are also less likely to have long-term complications if they have had their arteries opened. Although the complication rates in our elderly patients is higher, the benefits offered by this invasive treatment are also greater.

NSTEMI heart attacks are a bit different; they are the most common type of heart attacks, and they often occur when one of the blood vessels connected to the heart has a blood clot in it that does not completely block the artery. They can also be treated with angioplasty and stenting. We know from research studies that younger patients who present with this type of heart attack benefit from an angiogram. The findings from the angiogram then helps in the decision-making process regarding whether the patient would be best treated with angioplasty and stent insertion, tablets, or coronary artery bypass surgery (CABG).

However, it is not known whether this approach is also beneficial for the over 80s. Up until now, these patients have often been treated with tablets, rather than given an angiogram, due to concerns about the increased chance of complications from invasive treatments in older patients.

My research team at Imperial College London recently found that non-frail patients aged 80 and above who presented to hospital with an NSTEMI (Non-ST-elevation myocardial infarction) heart attack had a death rate that was a third lower when they had been treated with a coronary angiogram, compared with patients who were just treated with tablets. This indicates that invasive management can have substantial benefits for older patients.

We published the findings in The Lancet, and you can read the full research paper from the link provided below. The results demonstrated that there was a considerable benefit in treating older patients in a similar way to younger patients. This study emphasises that the treatments that we offer should not be determined by biological age and should instead be based on how robust patients look and feel. It is really important to discuss all of the available options with patients of all ages so that individuals can make a choice about which treatment is right for them.

Kaura A, Mayet J. et al. The Lancet 2020.