Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy.
Translational and Clinical Research Institute, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
Eur Heart J. 2024 Aug 16;45(31):2811-2823. doi: 10.1093/eurheartj/ehae435.
The mean age of patients with coronary artery disease (CAD) is steadily increasing. In older patients, there is a tendency to underutilize invasive approach, coronary revascularization, up-to-date pharmacological therapies, and secondary prevention strategies, including cardiac rehabilitation. Older adults with CAD commonly exhibit atypical symptoms, multi-vessel disease involvement, complex coronary anatomy, and a higher presence of risk factors and comorbidities. Although both invasive procedures and medical treatments are characterized by a higher risk of complications, avoidance may result in a suboptimal outcome. Often, overlooked factors, such as coronary microvascular disease, malnutrition, and poor physical performance, play a key role in determining prognosis, yet they are not routinely assessed or addressed in older patients. Historically, clinicians have relied on sub-analyses or observational findings to make clinical decisions, as older adults were frequently excluded or under-represented in clinical studies. Recently, dedicated evidence through randomized clinical trials has become available for older CAD patients. Nevertheless, the management of older CAD patients still raises several important questions. This review aims to comprehensively summarize and critically evaluate this emerging evidence, focusing on invasive management and coronary revascularization. Furthermore, it seeks to contextualize these interventions within the framework of improved risk stratification tools for older CAD patients, through user-friendly scales along with emphasizing the importance of promoting physical activity and exercise training to enhance the outcomes of invasive and medical treatments. This comprehensive approach may represent the key to improving prognosis in the complex and growing patient population of older CAD patients.
冠心病（CAD）患者的平均年龄稳步上升。在老年患者中，倾向于较少采用有创方法、冠状动脉血运重建、最新的药物治疗以及二级预防策略，包括心脏康复。患有 CAD 的老年患者常表现为非典型症状、多血管疾病、复杂的冠状动脉解剖结构，以及更高的风险因素和合并症发生率。尽管有创手术和药物治疗都具有更高的并发症风险，但避免治疗可能导致结果不理想。通常情况下，被忽视的因素，如冠状动脉微血管疾病、营养不良和身体机能差，在决定预后方面起着关键作用，但在老年患者中并未常规评估或处理。历史上，临床医生依赖于亚分析或观察性研究结果来做出临床决策，因为老年患者在临床研究中经常被排除或代表性不足。最近，针对老年 CAD 患者的专门随机临床试验证据已经可用。然而，老年 CAD 患者的管理仍然提出了几个重要问题。本综述旨在全面总结和批判性评估这一新出现的证据，重点关注有创治疗和冠状动脉血运重建。此外，通过易于使用的量表，在改善老年 CAD 患者风险分层工具的框架内，将这些干预措施置于上下文中，并强调促进体力活动和运动训练的重要性，以提高有创和药物治疗的效果。这种综合方法可能是改善复杂且不断增长的老年 CAD 患者群体预后的关键。
