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MAS RIESGOS, MENOS TRATAMIENTO: LA PARADOJA DE LOS PACIENTES ANCIANOS CON SINDROMES CORONARIOS AGUDOS

(especial para SIIC © Derechos reservados)
Análisis de las razones para esta conducta paradójica y sugerencias metodológicas para el manejo apropiado.
greco9.jpg Autor:
Cosimo Angelo Greco,
Columnista Experto de SIIC

Institución:
Uo CardiologiaFazzi Ospedale Vito Fazzi di Lecce Lecce, Italy


Artículos publicados por Cosimo Angelo Greco,
Coautores
Francesco Magliari, Medical Doctor, Cardiolog*  Antonio Montinaro Medical doctor, Cardiologis** 
U.O. Cardiologia/UTIC, Ospedale Vito Faz*
U.O. Cardiologia interventistica ed Emod**
Recepción del artículo
13 de Abril, 2004
Primera edición
4 de Mayo, 2005
Segunda edición, ampliada y corregida
7 de Junio, 2021

Resumen
Aunque los pacientes ancianos constituyen una población de alto riesgo, en la práctica diaria, paradójicamente, reciben terapia trombolítica y procedimientos intervencionistas con menor frecuencia que los pacientes más jóvenes. En este artículo analizamos los motivos de esta paradoja y sugerimos algunas pautas para el manejo clínico. El riesgo de sangrado con las drogas trombolíticas es el motivo principal por el cual se restringe en el anciano el tratamiento de reperfusión. La búsqueda de factores de riesgo para sangrado en cada paciente permite estratificar los pacientes en diferentes grupos o clases de riesgo. Esto puede ser de utilidad para indicar drogas trombolíticas a pacientes con riesgo de sangrado bajo y a aquellos que pueden tratarse dentro de las dos horas de iniciados los síntomas. En todos los demás debería considerarse la posibilidad de realizar una angioplastia coronaria primaria. En los pacientes añosos con angina inestable o infarto de miocardio sin elevación del ST, una estratificación del riesgo cautelosa y temprana guiará la indicación de procedimientos intervencionistas. Debe incentivarse su uso en pacientes de alto riesgo y buen estado general para que la terapia invasiva logre mejorar verdaderamente la calidad de vida de estos individuos.

Palabras clave
Infarto agudo de miocardio, angina inestable, tratamiento trombolítico, procedimiento/intervención coronaria percután


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Abstract
Although elderly patients are a high risk population, paradoxically, in the clinical setting, they receive thrombolytic therapy and interventional procedures less frequently than younger patients. In this overview we analyse the reasons of this paradox and we suggest some guidelines of management. The bleeding risk of thrombolytic drugs is the main cause that restrict the reperfusion therapy in the elderly patients. The identification of risk factors for bleeding in each patient can stratify the patients in different risk classes. This may encourage thrombolytic drugs administration to patients with a low risk of bleeding and to patients who can receive treatment within two hours after symptom onset, whereas for all the others the primary coronary angioplasty should be considered. In elderly patients with unstable angina or non ST-elevation myocardial infarction, a careful and early risk stratification should guide the indication to interventional procedures. The invasive therapy should be chosen for high risk patients and for patients with no poor general conditions so that it can really improve the quality of life.RiassuntoSebbene gli anziani siano una popolazione ad alto rischio, paradossalmente nella pratica clinica ricevono la terapia trombolitica e le procedure interventistiche meno frequentemente dei pazienti più giovani. In questa rassegna analizziamo le ragioni di questo paradosso e suggeriamo alcune linee guida di trattamento. La causa principale che determina una restrizione della terapia di riperfusione nei pazienti anziani è rappresentata dal rischio di sanguinamento legato ai farmaci trombolitici. La ricerca dei fattori di rischio di sanguinamento in ciascun paziente permette di stratificare ciascun paziente in differenti classi di rischio. Ciò può aiutare a somministrare i farmaci trombolitici nei pazienti a basso rischio di sanguinamento ed in quelli che possono essere trattati entro le prime due ore dall’insorgenza del dolore, considerando diversamente per tutti gli altri l’angioplastica primaria. Nei pazienti anziani con angina instabile o infarto miocardico acuto senza sopraslivellamento del tratto ST, una precoce ed accurata stratificazione del rischio dovrebbe guidare il medico nell’indicazione alle procedure interventistiche. Queste dovrebbero essere eseguite in pazienti ad alto rischio e senza condizioni generali precarie così che la terapia invasiva possa realmente migliorare la qualità della vita.

Key words
Acute myocardial infarction, unstable angina, thrombolytic therapy, percutaneous, coronary intervention, elderly


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Especialidades
Principal: Cardiología, Geriatría
Relacionadas: Atención Primaria, Bioética, Cuidados Intensivos, Medicina Familiar, Medicina Interna, Salud Pública



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