The first speaker, Dr W Scholte Op Reimer (Rotterdam, Netherlands) focused on what we can learn from various Euro Heart Surveys regarding the elderly. The Euro Heart Surveys provide us with data on more than 80,000 patients with a variety of heart diseases. There are, however, few evidence-based guidelines on how to treat elderly patients. Several challenges were outlined, such as the possibility of undertreatment, polypharmacy and co-morbidities, which complicate the picture. Dr Scholte Op Reimer suggested several courses of action including patient education, increasing compliance and earlier recognition of complications and side effects of medication.
Professor M C Deaton (Manchester, GB) focused on the elderly patient with coronary heart disease, specificially acute coronary syndromes (ACS). Although many of our patients are elderly, there is less evidence for practice in this group. Elderly patients with ACS often have atypical symptoms that are not recognised as cardiac and, less often, present with ST-elevation. Most therapies, including reperfusion and early invasive treatment, are not indicated due to age. Older patients benefit from aggressive treatment of ACS, but there is increased risk of adverse events, such as bleeding complications. Deaton concluded with a call for a paradigm shift in care: to teach what is typical for the elderly in ACS, to think geriatrics, modify therapies for elderly patients, develop geriatric competencies and to design services that benefit the elderly.
Dr D Fitzsimons (Belfast, GB) pointed out the fact that patients’ delay in seeking medical help when they experience the first symptoms of myocardial infarction (MI) contributes to higher mortality and morbidity. Also, it is evident that delay times in the elderly are longer than for younger patients. Dr Fitzsimons pointed out a number of factors that can contribute to this problem: the difficulty older patients may have differentiating cardiac symptoms from others, social factors such as living alone, and cognitive or sensory impairment. These factors represent a complex and challenging clinical picture and health professionals in a variety of settings must apply a wide repertoire of skills if elderly patients with symptoms of acute MI are to receive timely, evidence based care.
The majority of all heart failure patients are elderly, which makes the condition and its treatment more complex. Dr A Stromberg (Linkoping, Sweden) showed that follow-up by specialised heart failure programmes, often nurse-lead, can improve survival and the self-care behaviour in patients with heart failure, thus reducing the number of events (death/readmission) and the need for hospital care. The programme content covers intensive patient education, exercise counselling, self-care supportive strategies, detection and management of clinical deterioration and optimised treatment. Although heart failure programmes are recommended by guidelines, few patients receive this structured follow-up. However, many countries are now starting up these programmes.
The last speaker, Professor D Atar (Oslo, Norway), addressed the issue of polypharmacy in the elderly. He pointed out that polypharmacy in the elderly is extremely prevalent. The phenomenon is not only fully implemented in cardiovascular medicine, it is also in fact a hallmark of modern evidence-based medicine.
Professor Atar reported that the rate of side effects, interactions and adverse outcomes is low. Notably, the effects achieved with the usual cardiovascular medication in the elderly are as convincing as in the young, both in terms of mortality and morbidity, and even with regard to the quality of life. The key to success, however, is awareness of the particular frailty of the elderly. Atar gave the audience the advice “Start low – go slow”.