Octogenarians made up less than 5% of patients in the NCVD-ACS registry from 2008 until 2017, whereby NSTEMI presentation predominated. The frequencies of men and women did not differ, and the largest ethnic group were Chinese. Hypertension was the main CV risk factor. Worryingly, most octogenarians (90.4%) have multiple CV risk factors. The rates for in-hospital PCI has been increasing. There was a high percentage of patients prescribed anticoagulants, antiplatelets and lipid-lowering agents. However, less than half were being prescribed ACEIs/ARBs and beta-blockers. The presence of CV risk factors and comorbidities influences management. For example, those with congestive heart failure were more likely to be given PCI and evidence-based pharmacotherapies.
Malaysia is experiencing an increasing trend of the elderly population, which have surpassed 15 per cent. This change would burden the country’s economy due to increasing healthcare services demand (11). This study found increasing trend in the octogenarians with ACS. Age-related changes in vascular wall elasticity, coagulation and haemostatic system and endothelial functions become more apparent in this age group. The Swedish National registry reported that the cumulative incidence of MI, stroke and CVD mortality for those aged 80 years old and above are the highest amongst other age groups observed (12). Thus, the octogenarians represent an important group for policymakers to focus on in the coming years.
Although no significant differences were observed in gender presentation for ACS in the octogenarians, the rates of CV risk factors differed. There were higher rates of hypertension, diabetes mellitus and dyslipidaemia in women, while men had higher smokers and previous history of IHD. This finding is similar to the national health survey for adults in 2015 (13). The largest ethnic group in this pool of patients were Chinese, in contrast to the demographic distribution of the country, where Malays are the majority (14). This ethnic variation was also different from the ACS demographics in younger age groups, using the same registry (15). The Chinese predominance could be due to several reasons such as longer lifespan, healthier lifestyle and geographical location. The Chinese reside primarily in urban areas where healthcare services are nearby (16). They have the lowest prevalence of CV risk factors and physical inactivity than other ethnicities (17, 18).
There is a high prevalence of octogenarians with multiple risk factors. These risk factors may affect the presentation and the severity of CHD and the complexity of managing them. Hypertension remains the major risk factor. Thus, advocating evidence-based management to treat hypertension may result in a more favourable outcome (19). More than forty per cent of patients have diabetes mellitus, which is higher than observed in other populations in the African, European, Northern America and the Western Pacific region (20). Diabetes mellitus on its own is associated with other comorbidities such as chronic kidney disease and thus needs to be managed carefully in this group of patients. Comorbidities such as congestive heart failure have also influenced the choice of management of ACS in these patients.
This study showed an increasing trend of PCI in octogenarians with STEMI. The advantages of PCI is debatable in old age. The most common non-cardiac complication of PCI is bleeding, associated with a higher risk of death in the elderly, especially in the presence of comorbidities (21). Despite this, studies have shown the benefits of PCI in this group. The Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) trial found a strong trend of lower 30-days mortality rates in patients ≥ 70 years old treated with PCI, compared to thrombolysis (22). PCI-treated patients had higher target vessel revascularisation at follow-up in the Primary Coronary Angioplasty Trial (PCAT) (23), suggesting acceptable long-term outcomes for octogenarians (24). CABG was not preferred in our population, most likely influenced by their frailties and comorbidities (25). The rate of PCI will likely continue to increase in the coming years; therefore, skilled cardiologists and equipped facilities are essentials.
The treatment for NSTEMI and UA is mainly through pharmacotherapies proposed by internationally approved guidelines such as antiplatelets and anticoagulants (26–28). This practice is reflected in this study, whereby NSTEMI and UA were less likely given PCI but more likely to receive anticoagulants than STEMI. Interestingly, the ‘After Eighty’ study has suggested that participants with NSTEMI and UA may have better outcomes with higher success rates and lesser complication after PCI procedures compared to those treated with optimum medical treatment alone (29).
The evidence-based pharmacotherapies for immediate ACS treatment include antiplatelets, anticoagulants, statins, ACEIs/ARBs and beta-blockers. Those who received recommended therapies were shown to have lower in-hospital mortality than those who did not (30). Antiplatelets were prescribed maximally in this population. Aspirin has been used in ACS for decades (28, 31). Recently, guidelines recommended the use of DAPT (28). The prescribing of DAPT has increased in octogenarian patients. Bleeding remains a significant adverse effect for DAPT. There is still room for improvement for ACEIs/ARBs and beta-blockers in this population. Similar trends were seen in the younger age group in the NCVD-ACS registry (15, 32). The CRUSADE study reported that beta-blockers were also less likely to be prescribed in elderly patients (30). Physicians need to be aware of age-related physiological changes that may affect the pharmacokinetics and pharmacodynamics of these drugs in octogenarians while considering the immediate and long-term benefits.
We need to bridge the knowledge gap on the effectiveness and risks of current management by performing clinical studies in the local setting. An example that could be modelled is Finland’s follow-up accumulation of risk factor study (33) and the After Eighty case-control study. As ACS has a multifactorial aetiology, a modelling study could be performed to investigate the contributions of each risk factor and how management impacted the outcomes. One example is the IMPACT-CHD model used in the Italian and Portugal population that have shown death prevented and postponed in women aged ≥ 75 were higher than men (34, 35). At these bonus plus years that the octogenarians currently enjoy, dipping into already scarce resources, the question most would not dare to ask is, “is it worth spending so much only to prolonged something inevitable?”.
Strength and limitations
This study uses data from a nationwide cardiology registry obtained from 23 hospitals to represent an unselected group of octogenarian patients with ACS in a real-world setting in this country. The database is well maintained, and training is provided regularly for those involved to ensure data quality (36–38). Information that measures socioeconomic status may influence demographics presentation, such as occupation and educational levels, were not available. However, most octogenarians are often retired. Participation of hospitals in this database is voluntary, and there may be a selection bias. Many private hospitals did not participate in this registry. Thus, the pattern of octogenarians with ACS in this sector could not be determined. However, private hospitals mainly cater for self-paying or health insurance schemes; therefore, the utilisation in octogenarians may be less than other age groups due to financial restrictions at this extreme age.