The Effect of Primary Angioplasty and Drug Therapy in Elderly Patients with Acute Coronary Syndrome

The aging of the population has caused an increase in the number of elderly people who receive treatment for cardiovascular disease. The prevalence of coronary artery disease is higher in the elderly, and on the other hand, complications after cardiac events are worse in the elderly. The most common cause of death in the elderly is cardiovascular disease. Rapid restoration of blood flow can lead to myocardial survival, preservation of cardiac function, and prolongation of the patient's life, and many clinical trial studies have been conducted to investigate the effect of Thrombolytics, and their results showed that Thrombolytics preserve ventricular function. Primary coronary angioplasty was defined as the primary revascularization strategy for acute myocardial infarction without or with prior thrombolytic therapy. In the last two decades, it has been shown that the complications of coronary artery syndrome have decreased with the development of therapeutic strategies such as revascularization, medical treatment, and risk factors in follow-up after discharge. Data from many cardiovascular centers have shown that angioplasty not only leads to a significant reduction in mortality but also in coronary ischemic events. Elderly people who have concurrent diseases such as lung diseases, kidney diseases, and cerebrovascular accidents and suffer from coronary accidents accept angioplasty with caution. This is even though in symptomatic patients with chronic coronary disease, revascularization leads to the resolution of symptoms and improvement of the patient's life expectancy. Despite the effects of coronary artery disease on the quality of life, morbidity, and mortality of the elderly, in the majority of cardiovascular studies, the elderly 75 years and older were significantly less expressed and directly due to advanced age, and complex co-morbidities, and significant physical and cognitive disabilities., fatigue, living in a nursing home, and decline in daily functioning were excluded from the study. Therefore, recent guidelines cannot provide evidence-based recommendations for the diagnosis and treatment of coronary diseases in the elderly. Choosing the correct treatment strategy for the elderly with acute coronary artery disease is due to the importance of the burden of care from the economic, social, and family points of view. Also, few studies are comparing the effect of medical treatment with revascularization in the elderly 75 years and older. The aim of the study is to determine whether elderly people benefit from primary angioplasty compared to medical treatment alone and the side effects of each of these treatments in the elderly.

The present study is a prospective cohort type, which was approved by the ethical code IR.TUMS.MEDICINE.REC.1397.934 in the ethical code commission of the Faculty of Medicine of Tehran University of Medical Sciences and 97 samples were taken in 9 months from June 2018 to the end of March. were collected and then for 24 hours and 30 days after the treatment (medical/angioplasty), the elderly (mostly 60 years old) with acute coronary artery disease were followed up in terms of the effectiveness and side effects of the treatments. All elderly people diagnosed with acute coronary syndrome hospitalized in two teaching hospitals of Tehran University of Medical Sciences were included in the study and evaluated in two groups. The first group of the interventional treatment group: was patients who were diagnosed with acute coronary syndrome and were treated with angioplasty from the beginning, and the second group, the optimal medical treatment group: patients who were treated with standard medical treatment from the beginning (including Thrombolytics, oral beta blockers, intravenous nitrates, antiplatelet Duals such as aspirin and Clopidogrel, intravenous anticoagulants such as heparin or enoxaparin, statin and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers 2) were included according to the latest guidelines. In this prospective cohort study, all patients aged 60 years and older with the acute coronary syndrome were collected by face-to-face interview and case evaluation from two teaching hospitals, Tehran University of Medical Sciences from 2018, and they were divided into two primary and medical angioplasty groups in terms of complications., mortality and efficacy of 24 hours and 30 days were compared.

Out of 120 patients with an average age of 71.2±8.2 years, 52 and 68 patients received primary angioplasty and medical treatment, respectively. The majority of patients in the primary angioplasty group were male (57.7%) and female (57.4%) in the medical group (p=0.07). In the first 24 hours, comparing the two groups with the logistic regression method, atrial fibrillation was significantly 11 times higher in the medical group (p=0.016) and improvement of angina in the primary angioplasty group was 3.8 times higher (p=0.04). The 30-day mortality rate was significantly higher in the medical group (p=0.006).

These results indicate that we overestimate the risks associated with revascularization in the elderly and deprive people of useful treatments. With increasing age, despite the significant reduction of hospital and short-term mortality by about 5 times, increasing the rate of angina recovery and fewer complications in angioplasty, this treatment method is less often chosen in elderly patients, and elderly people are less likely to choose this method due to their age. They are denied treatment. There are sufficient reasons for the elderly and very elderly with good tolerance to angioplasty. The success rate of immediate angioplasty and the survival rate without complications are similar to young patients, so old age is not a contraindication for angioplasty. Also, old age is not an independent risk factor for poor prognosis. In addition, complete revascularization in very elderly patients may improve prognosis and reduce the incidence of cardiac events. This study included limitations. Collecting samples from two different hospitals, one of these hospitals was not able to perform angioplasty in patients with angioplasty indication due to the lack of an angiography department, and the patients were forced to undergo medical treatment, which also led to a decrease in the number of The samples included in the angioplasty group and the bias in the selection of patients with real indications for medical treatment. On the other hand, it also leads to an increase in complications. The low sample size and the age of the patients included in the study were among the limitations of this study.