八旬老人非 ST 段抬高型急性心肌梗死的侵入策略

Sara Álvarez-Zaballos, M. Juárez-Fernández, M. Martínez-Sellés
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摘要

随着人口老龄化和心血管风险因素的累积,越来越多的急性冠状动脉综合征(ACS)患者是八旬老人(年龄在 80-89 岁之间)。由于年龄、合并症、虚弱和其他老年病等多种因素,这一人群具有明显的异质性。所有这些变量都对治疗效果有很大影响。此外,多血管疾病、复杂冠状动脉解剖和外周动脉疾病的高发病率也增加了这些患者进行侵入性手术的风险。对于高龄患者,抗血栓治疗的类型和持续时间需要根据出血风险进行个体化。虽然一般人群都建议对非 ST 段抬高型急性心肌梗死(NSTEMI)采取侵入性治疗策略,但对于八旬老人来说,其必要性并不明显。例如,虽然体弱的患者可以从血管重建中获益,但他们的并发症风险较高,可能会改变风险/收益比。在决定策略类型时,年龄不应是主要考虑因素。还需要考虑无效的风险,识别不良后果的风险因素(如肾功能损害)有助于决策过程。最后,最初选定的保守治疗策略应根据临床过程(心绞痛复发、室性心律失常、心力衰竭)来决定是否改为侵入性治疗。随着人口的不断增长,迫切需要进一步的证据,最好是来自前瞻性随机临床试验的证据。
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Invasive Strategy in Octogenarians with Non-ST-Segment Elevation Acute Myocardial Infarction
With population aging and the subsequent accumulation of cardiovascular risk factors, a growing proportion of patients presenting with acute coronary syndrome (ACS) are octogenarian (aged between 80 and 89). The marked heterogeneity of this population is due to several factors like age, comorbidities, frailty, and other geriatric conditions. All these variables have a strong impact on outcomes. In addition, a high prevalence of multivessel disease, complex coronary anatomies, and peripheral arterial disease, increases the risk of invasive procedures in these patients. In advanced age, the type and duration of antithrombotic therapy need to be individualized according to bleeding risk. Although an invasive strategy for non-ST-segment elevation acute myocardial infarction (NSTEMI) is recommended for the general population, its need is not so clear in octogenarians. For instance, although frail patients could benefit from revascularization, their higher risk of complications might change the risk/benefit ratio. Age alone should not be the main factor to consider when deciding the type of strategy. The risk of futility needs to be taken into account and identification of risk factors for adverse outcomes, such as renal impairment, could help in the decision-making process. Finally, an initially selected conservative strategy should be open to a change to invasive management depending on the clinical course (recurrent angina, ventricular arrhythmias, heart failure). Further evidence, ideally from prospective randomized clinical trials is urgent, as the population keeps growing.
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