Myocardial infarction in the very old: Not just the cardiologist’s business!

Dr. Alain Putot, MD, PhD, is a French geriatrician specialising in geriatric acute care. He is involved in collaborative research at the crossroads between medical specialties, to better address the diagnosis and management of myocardial infarction in the very old. His expert review New horizons in Type 2 myocardial infarction: pathogenesis, assessment and management of an emerging geriatric disease was recently published in Age and Ageing journal.

It is a fact - at least in France - that patients with a myocardial infarction (MI) are referred to cardiologists as a priority. Of course, this makes sense when cardiovascular expertise is the priority, e.g. in the case of cardiogenic shock or in the case of ST segment elevation. Age alone cannot be an argument for depriving our patients of cardiological expertise and technical care, especially coronary angioplasty, that have radically changed the prognosis of MI in all age groups in the past decades.

However, the management of MI in the very old should not be limited to this technical issue of an occluded artery. Firstly, because the occluded artery often belongs to a frail person who is particularly important to consider as a whole. Secondly, because it appears that the artery is not always occluded! In fact, the older the patient, the lower the probability that the MI is due to an atherothrombotic event. This is the concept of functional MI, called type 2 infarction in the universal definition of MI and presented in the attached review. In type 2 MI, the ischaemia is not related to an atherothrombotic process (type 1 MI) but to an imbalance in myocardial oxygen supply and demand. This condition predominantly affects multimorbid individuals with a history of cardiovascular disease. However, the conditions that lead to the functional imbalance between oxygen supply and demand are frequently extracardiac (e.g. pneumonia or anaemia). The great heterogeneity of the underlying aetiological factors requires a comprehensive approach that is tailored to each case. In the absence of evidence for the benefit of invasive reperfusion strategies, the treatment of type 2 MI remains to date essentially based on the restoration of the balance between oxygen supply and demand. For older multimorbid patients with type 2 MI, geriatricians and cardiologists need to work together to optimise aetiological investigations, treatment and prevention of predisposing conditions and precipitating factors.

On the model of what has been developed in oncogeriatrics or orthogeriatrics, i.e. units dedicated to the specific needs of older patients, it is high time to see the emergence of cardiogeriatric care units, which could bring together the cross-disciplinary expertise of these two fascinating disciplines, for the benefit of these patients whose care is so challenging.