Letters Acute coronary syndromes

Acute coronary syndromes: what about older patients with frailty and multiple comorbidities?

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6346 (Published 25 November 2015) Cite this as: BMJ 2015;351:h6346
  1. Sean G Ninan, clinical leadership fellow and geriatric medicine registrar1
  1. 1Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds LS9 7TF, UK
  1. sean.ninan{at}nhs.net

Timmis’s useful article does not refer to the management of older patients with multimorbidity, a common scenario in clinical practice.1 Only 14% of participants in clinical trials are over 75 years,2 yet Myocardial Ischaemia National Audit Project registry data indicate that around 40% of patients with acute coronary syndromes are in that age group.3 As well as being under-represented, older participants in clinical trials have relatively few comorbidities and may not have much in common with the frail older patients seen in clinical practice.3 4

Although older people should never be denied high quality treatment on the basis of age alone, frail older people with comorbidities such as anaemia, heart failure, and chronic kidney disease are at higher risk of bleeding, and bleeding is associated with an increased risk of adverse outcomes and death.5 6 The risk of bleeding can be estimated using a scoring tool such as CRUSADE.7 For example, an 80 year old woman with stage 4 chronic kidney disease, chronic heart failure, and peripheral vascular disease has about a 20% risk of in-hospital major bleeding.8

The presence of comorbidities and polypharmacy, the benefit from treatment, the likelihood of harm, and the patient’s preferences and life expectancy should all be taken into consideration in frail older patients.9 Future guidelines should take into account multimorbidity to provide patient centred care that reflects the heterogeneity of clinical practice not seen in randomised controlled trials.10


Cite this as: BMJ 2015;351:h6346


  • Competing interests: None declared.


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