Evidence of ageism in the management of acute coronary syndromes

SIR—Elder rightly points out that older people with acute coronary syndrome (ACS) are treated differently to younger patients [1]. Several studies have shown that they are less likely to receive evidence-based treatments despite higher risk of major coronary events. Although I agree that evidence of ageism is mounting and it probably does exist, the case is not yet proven. Could the differences in management and outcome be explained by confounding factors? In particular, data about co-morbidity in older patients are lacking. Older patients presenting with ACS typically had three other morbid conditions in one study [2]. Another recent study found an invasive strategy could safely and successfully be implemented in 77% of unselected patients with ACS aged 70 or over [3]. All the increase in rate of adverse events observed in the older cohort in the study arose from the remaining 23% who had contraindications. Outcomes were similar to other published series despite intention to treat aggressively irrespective of age. Elder identifies two big obstacles to ensure compliance with National Service Frameworks for Older People and Coronary Heart Disease. The first is the limited availability of invasive interventions. Wherever there are limited resources it is always likely that those perceived to have lower life expectancy, whether due to co-morbidity or advanced age only, will lose out. Unless it can be proven that many interventions are ‘wasted’ on younger patients, it would be harsh to claim this is ageism. It has been estimated that achieving equity for women and older people up to the age of 79 would necessitate over 27,000 extra coronary artery bypass grafts and over 23,000 extra percutaneous interventions in England alone [4]. The second relates to patient selection. The management of acute coronary syndrome relies on risk stratification to identify those most likely to benefit from aggressive intervention [5]. Where is the evidence that commonly used risk stratification tools (e.g. ECG, troponin levels) are useful for identifying older patients who would benefit from intervention? The limitations of such simple tools have led to the development of more robust instruments. The GRACE (Global Registry of Acute Coronary Events) model is possibly the best, as it was developed from a large number of relatively unselected patients [6]. It is interesting that even this model performs worse (lower area under receiver operating characteristic curves) in the elderly than in any other sub-group. Unless these issues can be resolved it is unlikely that older patients with ACS will benefit from similar treatment or outcomes than younger patients, and it will be impossible to prove that such inequalities are due to ageism.