WHAT IS PEER TO PEER?
Med-IQ's new complimentary, certified continuing medical education (CME) activity,
Peer to Peer: A New Model for Improving Guideline- and Evidence-Based ACS Care, is connecting healthcare professionals from across the country. This exciting, first-of-its-kind CME series provides participants with access to acute coronary syndrome (ACS) faculty experts during personalized sessions focusing on improving ACS patient care in their practices. This real-time exchange of ideas has helped address some of the major challenges that clinical practices face in managing ACS cases.

WHAT ARE E-BRIEFS?
Each month, Med-IQ will publish a short e-brief to highlight real-world questions, opportunities for improvement, and front-line perspectives gained from these ACS Peer to Peer teleconferences. Below, you'll find the fifth of these e-briefs; in this installment, our expert faculty answer some questions about evaluating specific patient populations posed by participants in our peer-to-peer teleconferences.

Women and older patients constitute a significant portion of patients presenting with unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI). In this e-brief, expert faculty discuss with participants why risk assessment, diagnosis, and selection of treatment strategy are more challenging in these patients and highlight some of the unique factors that should be considered when evaluating women and the elderly for ACS. In addition, faculty explore some of the recommendations that the 2007 ACC/AHA UA/NSTEMI guidelines offer on ACS care in women and older patients.

Identifying At-Risk Female Patients
Question: What are the differences in presentation between male and female patients with ACS? How can women who have a high risk of adverse outcomes be identified?

Answer: Although chest pain is the most common symptom in both men and women, women are more likely to experience back and jaw pain, nausea, vomiting, dyspnea, indigestion, palpitations, dizziness, fatigue, loss of appetite, and syncope.¹ Thus, it is important to not dismiss these atypical symptoms, particularly in female patients, and to overcome the often-held misconception that ACS is uncommon in women.

An analysis of the TACTICS-TIMI 18 found that women with UA/NSTEMI were more likely to have elevated C-reactive protein and brain natriuretic peptide (BNP) at presentation and less likely to have elevated troponin levels and CK-MB.² Thus, measurement of BNP or NT-pro-BNP might be considered to identify at-risk female patients with normal or equivocal troponin levels. That said, elevated troponin is just as prognostic for adverse outcomes in women as it is in men.² Women are just as likely to have ST-segment changes as men, but they are more likely to have T-wave inversion. On angiography, they often have less-severe coronary artery disease than men, and it is more likely to be nonobstructive.³

Even though the 2007 ACC/AHA UA/NSTEMI guidelines recommend that women should receive the same noninvasive testing and pharmacologic therapy as men, characteristics of ACS presentation in women make diagnosing UA/NSTEMI more challenging and may result in the underuse of effective treatments.⁴ While women with high-risk features should receive similar invasive strategies as men, guidelines indicate that women who have a low risk should not undergo invasive treatments; this is emphasized in the guidelines by data from recent clinical trials suggesting that invasive strategies in this group increase the risk of adverse events.⁴

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Managing Elderly Patients
Question: What is the best therapeutic approach for managing patients 75 years or older who present with nonspecific or atypical symptoms and a nondiagnostic ECG, but who are troponin-positive?

Answer: In those with possible ACS, even a mildly elevated troponin is a sign that the patient has a high risk of experiencing an adverse outcome. The question is, does this patient have ACS? This isn’t always easy to determine in frail, older adults. The elderly are more likely to present with atypical symptoms. Moreover, they often have comorbidities that can also result in chest discomfort, such as gastroesophageal reflux disease, upper body musculoskeletal pain, and chronic obstructive pulmonary disease. Pulmonary embolism, sepsis, and congestive heart failure—all common in older patients—may also elevate troponin and should be ruled out. However, if the patient does have symptoms indicative of ACS—ongoing chest pain or discomfort with shortness of breath, diaphoresis, or nausea—in conjunction with elevated troponin, guidelines indicate that an aggressive strategy is warranted.^4,5

Unfortunately, clinical trial evidence is limited with regard to the efficacy and hazards of pharmacologic and invasive management of UA/NSTEMI in the elderly.⁵ Existing data suggest that the elderly are at higher baseline risk of adverse outcomes from ACS and that they also face increased procedural risk and higher rates of complications with revascularization when compared with younger patients. The absolute benefits observed in trials, however, suggest that age alone should not prevent consideration of invasive strategies.⁴

In clinical practice, it can be very difficult to decide on using an invasive strategy in an elderly patient, especially one who may have renal insufficiency or other comorbidities. Cardiologists and/or internists need to balance increased bleeding and procedural risks with reported benefits when determining appropriate management strategies and selecting antithrombotic agents.

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Determining Treatment for Elderly Hemodynamically Unstable Patients
Question: According to the ACC/AHA guidelines, hemodynamic instability is an indication for an invasive strategy. But what strategy is best for the very elderly patient who is hemodynamically unstable—say, with a systolic blood pressure of 90 mmHg—and has atypical ACS symptoms and/or nonspecific findings?

Answer: Given the possible complications of an invasive strategy, a more conservative approach may be wise, despite the guideline recommendation. Unless the patient has ST-segment elevation, one approach is to medically manage the patient while monitoring troponin levels and ECGs, and then reconsider the benefits and risks of an invasive strategy when the patient is more stable.

When making treatment decisions in older patients, the 2007 ACC/AHA UA/NSTEMI guidelines recommend considering general medical and cognitive status, bleeding and other intervention-related risks, anticipated life expectancy, and patient or family preferences.⁴

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REFERENCES

1. Patel H, Rosengren A, Ekman I. Symptoms in acute coronary syndromes: does sex make a difference? Am Heart J. 2004;148(1):27-233.

2. Wiviott SD, Cannon CP, Morrow DA, et al. Differential expression of cardiac biomarkers by gender in patients with unstable angina/non-ST-elevation myocardial infarction: a TACTICS-TIMI 18 (Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction 18) substudy. Circulation. 2004;109(5):580-586.

3. Glaser R, Herrmann HC, Murphy SA, et al. Benefit of an early invasive management strategy in women with acute coronary syndromes. JAMA. 2002;288(24):3124-3129.

4. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007;116(7):e148-e304.

5. Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115(19):2549-2569.

"This was a 5-star activity—over the top!" — Physician Participant, Las Vegas, NV

This activity is supported by an educational grant from sanofi-aventis U.S.

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