Острый коронарный синдром без подъема сегмента ST у пациентов старческого возраста и долгожителей. Особенности лечения. Обзор литературы и клинический случай

Несмотря на растущую с каждым годом популяцию людей старческого возраста и долгожителей, лечение острого коронарного синдрома в этих группах остается мало освещенной темой, не регламентированной в клинических рекомендациях ввиду отсутствия крупных рандомизированных клинических испытаний.

В статье представлен обзор литературы, охватывающий основные вопросы, возникающие в ходе принятия клинических решений при лечении острого коронарного синдрома без подъема сегмента ST у данной группы больных: выбор инвазивной тактики лечения, объема реваскуляризации миокарда, назначение двойной антитромбоцитарной терапии с учетом риска кровотечений, снижения почечной функции и старческой астении.

Кроме того, представлен клинический случай успешного лечения 101-летней пациентки с инфарктом миокарда без подъема сегмента ST, которой было проведено чрескожное коронарное вмешательство со стентированием инфаркт-связанной артерии.

1. United Nations Department of Economic and Social Affairs. World Population Prospects: The 2015 Revision, Key Findings and Advance Tables; United Nations Department of Economic and Social Affairs: New York, NY, USA, 2015.

2. Koroukian SM, Schiltz N, Warner DF, et al. Combinations of chronic conditions, functional limitations, and geriatric syndromes that predict health outcomes. J Gen Intern Med. 2016;31:630-7. doi:10.1007/s11606-016-3590-9.

3. Dunlay SM, Chamberlain AM. Multimorbidity in older patients with cardiovascular disease. Curr Cardiovasc Risk Rep. 2016;10:3. doi:10.1007/s12170-016-0491-8.

4. Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306:840-7. doi:10.1001/jama.2011.1206.

5. Goldberg RM, Mabee J, Chan L, Wong S. Drug-drug and drug-disease interactions in the ED: analysis of a high-risk population. Am J Emerg Med. 1996;14:447-50. doi:10.1016/S0735-6757(96)90147-3.

6. Damluji AA, Forman DE, van Diepen S, et al. Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association. Circulation. 2020;14;141(2):e6-e32. doi:10.1161/CIR.0000000000000741.

7. CHez-Villanueva P, Ariza-Sole A, Vidan MT, et al. Recommendations of the Geriatric Cardiology Section of the Spanish Society of Cardiology for the assessment of frailty in the elderly patients with heart disease. Rev Esp Cardiol. 2019;72:63-71. doi:10.1016/j.rec.2018.06.035.

8. Dou Q, Wang W, Wang H, et al. Prognostic value of frailty in elderly patients with acute coronary syndrome: a systematic review and meta-analysis. BMC Geriatrics. 2019;19:222. doi:10.1186/s12877-019-1242-8.

9. Rodriguez-Queralto O, Formigo F, Lopes-Palop R, et al. FRAIL Scale also Predicts LongTerm Outcomes in Older Patients With Acute Coronary Syndromes. Med Dir Assoc. 2020;21(5):683-7.e1. doi:10.1016/j.jamda.2019.10.007.

10. Sanchis J, Bonanad C, Ruiz V, et al. Frailty and other geriatric conditions for risk stratification of older patients with acute coronary syndrome. Am Heart J. 2014;168(5):784-91.e2. doi:10.1016/j.ahj.2014.07.022.

11. Nunez J, Ruiz V, Bonanad C, et al. Percutaneous coronary intervention and recurrent hospitalizations in elderly patients with non ST-segment acute coronary syndrome: The role of frailty. Int J Cardiol. 2017;228:456-8. doi:10.1016/j.ijcard.2016.11.151.

12. Noriega FJ, Vidan MT, Sanchez E, et al. Incidence and impact of delirium on clinical outcomes in older patients hospitalized for acute cardiac diseases. Am Heart J. 2015;170:938-44. doi:10.1016/j.ahj.2015.08.007.

13. Tonet E, Campo G, Maietti E, et al. Nutritional status and all-cause mortality in older adults with acute coronary syndrome. Clin Nutri. 2020;39(5):1572-9. doi:10.1016/j.clnu.2019.06.025.

14. Komici K, Vitale DF, Mancini A, et al. Important of malnutrition on long-term mortality in elderly patients with acute myocardial infarction. Nutrients. 2019;11:E224. doi:10.3390/nu11020224.

15. Forman DE, Arena R, Boxer R, et al. Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2017;18;135(16):e894-e918. doi:10.1161/CIR.0000000000000483.

16. Collet J-P, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2021;42(23):2298. doi:10.1093/eurheartj/ehab285. Erratum for: Eur Heart J. 2021;42(14):1289-367.

17. Барбараш О. Л., Дупляков Д. В., Затейщиков Д. А. и др. Острый коронарный синдром без подъема сегмента ST электрокардиограммы. Клинические рекомендации 2020. Российский кардиологический журнал. 2021;26(4):4449. doi:10.15829/1560-4071-2021-4449.

18. Skolnick AH, Alexander KP, Chen AY, et al. Characteristics, management, and outcomes of 5,557 patients age > or = 90 years with acute coronary syndromes: results from the CRUSADE Initiative. J Am Coll Cardiol. 2007;49:1790-7. doi:10.1016/j.jacc.2007.01.066.

19. Devlin G, Gore JM, Elliott J, et al. Management and month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: The Global Registry of Acute Coronary Events. Eur Heart J. 2008;29(10):1275-82. doi:10.1093/eurheartj/ehn124.

20. Chen L, Han L, Luo J. Selection of percutaneous coronary intervention in elderly patients with acute myocardial infarction in tertiary hospital. Medicine (Baltimore). 2019;98(29):e16544. doi:10.1097/MD.0000000000016544.

21. Damman P, Clayton T, Wallentin L, et al. Effects of age on long-term outcomes after a routine invasive or selective invasive strategy in patients presenting with non-ST segment elevation acute coronary syndromes: a collaborative analysis of individual data from the FRISC II — ICTUS — RITA-3 (FIR) trials. Heart. 2012;98(3):207-13. doi:10.1136/heartjnl-2011-300453.

22. Savonitto S, Cavallini C, Petronio AS, et al. Early Aggressive Versus Initially Conservative Treatment in Elderly Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. JACC: Cardiovascular Interventions. 2012;5(9):906-16. doi:10.1016/j.jcin.2012.06.008.

23. Tegn N, Abdelnoor M, Aaberge L, et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial. Lancet. 2016;387(10023):1057-65. doi:10.1016/S0140-6736(15)01166-6.

24. Tropeano F, Leoncini M, Toso A, et al. Impact of Rosuvastatin in Contrast-Induced Acute Kidney Injury in the Elderly. J Cardiovasc Pharmacol Ther. 2016;21(2);159-66. doi:10.1177/1074248415599062.

25. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. ESC Scientific Document Group, 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40:87-165. doi:10.1093/eurheartj/ehy394.

26. Wang TY, McCoy LA, Bhatt DL, et al. Multivessel vs culprit-only percutaneous coronary intervention among patients 65 years or older with acute myocardial infarction. Am Heart J. 2016;172:9-18. doi:10.1016/j.ahj.2015.10.017.

27. Ibrahim H, Sharma PK, Cohen DJ, et al. Multivessel versus culprit vessel-only percutaneous coronary intervention among patients with acute myocardial infarction: insights from the TRANSLATE-ACS observational study. J Am Heart Assoc. 2017;6:e006343. doi:10.1161/JAHA.117.006343.

28. Capodanno D, Angiolillo DJ. Antithrombotic therapy in the elderly. J Am Coll Cardiol. 2010;56:1683-92. doi:10.1016/j.jacc.2010.04.063.

29. Danchin N, Lettino M, Zeymer U, et al. Use, patient selection and outcomes of P2Y12 receptor inhibitor treatment in patients with STEMI based on contemporary European registries. Eur Heart J Cardiovasc Pharmacother. 2016;2:152-67. doi:10.1093/ehjcvp/pvw003.

30. Zeymer U, Widimsky P, Danchin N, et al. P2Y12 receptor inhibitors in patients with non-ST-elevation acute coronary syndrome in the real world: use, patient selection, and outcomes from contemporary European registries. Eur Heart J Cardiovasc Pharmacother. 2016;2(4):229-43. doi:10.1093/ehjcvp/pvw005.

31. Savonitto S, Ferri LA, Piatti L, et al. A comparison of reduced dose prasugrel and standard-dose clopidogrel in elderly patients with acute coronary syndromes undergoing early percutaneous revascularization. Circulation. 2018;137:2435-45. doi:10.1161/CIRCULATIONAHA.117.032180.

32. Ariza-Sole A, Formiga F, Bard^ A, et al. Clinical characteristics and prognosis of very elderly patients with acute coronary syndrome treated with ticagrelor: insights from the LONGEVO-SCA Registry. Rev Esp Cardiol (Engl Ed). 2019;72:263-6. doi:10.1016/j.rec.2018.01.020.

33. Costa F, van Klaveren D, James S, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual patient datasets from clinical trials. Lancet. 2017;11;389(10073):1025-34. doi:10.1016/S0140-6736(17)30397-5.

34. Gimbel M, Qaderdan K, Willemsen L, et al. Clopidogrel versus ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation acute coronary syndrome (POPular AGE): the randomised, open-label, non-inferiority trial. Lancet. 2020;25;395(10233):1374-81. doi:10.1016/S0140-6736(20)30325-1.

35. Claassens DMF, Vos GJA, Bergmeijer TO, et al. A Genotype-Guided Strategy for Oral P2Y12 Inhibitors in Primary PCI. N Engl J Med. 2019;381(17):1621-31. doi:10.1056/NEJMoa1907096.

36. Lee S-Y, Hong M-K, Palmerini T, et al. Short-Term Versus Long-Term Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation in Elderly Patients. JACC: Cardiovasc Interv. 2018;11(5):435-43. doi:10.1016/j.jcin.2017.10.015.