IJCS | Volume 32, Nº5, September/October 2019

DOI: 10.5935/2359-4802.20190070 457 EDITORIAL International Journal of Cardiovascular Sciences. 2019;32(5):457-459 Mailing Address: Roberto Esporcatte Rua Mena Barreto, 29. Postal Code: 22271-100, Botafogo, Rio de Janeiro, RJ – Brazil. E-mail: resporcatte@globo.com Antiplatelet Therapy for Elderly Patients: When Less May Be More Roberto Esporcatte 1, 2 a nd Fernando Oswaldo Dias Rangel 1 Hospital Pró-Cardíaco, 1 Rio de Janeiro, RJ – Brazil Faculdade de Ciências Médicas - Hospital Universitário Pedro Ernesto (UERJ), 2 Rio de Janeiro, RJ – Brazil Editorial related to the article: Is There Safety in the Use of Clopidogrel Loading Dose in Patients Over 75 Years of Age with Acute Coronary Syndrome? Platelet Aggregation Inhibitors/therapeutic use; Aged; Hemorrhage; Acute Coronary Syndrome. Keywords “Seventy is old enough. After that there is too much risk” Mark Twain, 1897 In the last two decades, double antiplatelet therapy, together with percutaneous coronary intervention (PCI), has become a cornerstone of acute coronary syndrome (ACS) treatment and its use is recommended as early as possible, although there are many unanswered questions about the efficacy and safety of loading dose (LD), best moment of administration, clinical scenarios and, especially, its use in elderly patients. Despite the fact that elderly patients represent approximately 30% of the population admitted for ACS, they are virtually excluded from large clinical trials, receive fewer diagnostic and therapeutic approaches and have more ischemic and hemorrhagic complications. 1 Pretreatment and LD of P2Y12 antagonists bring potential benefits of increased myocardial infarction- related patency rate and reduction of peri-procedure myocardial infarction, stent thrombosis and vascular reocclusion. In contrast, there is a higher risk of bleeding related to PCI and possible myocardial revascularization surgery and inadvertent use in patients with contraindications. The study published in this issue, by Soeiro et al., 2 brings important questions regarding the safety of clopidogrel LD for elderly patients admitted for ACS. Clinical outcomes were analyzed in a sample of patients with mean age of 80 years, according to a LD of 75 mg (group I, n = 129) or 300 to 600 mg (group II, n = 45). As a result of the retrospective, observational, unicentric trial design and a small number of patients, there was great heterogeneity between groups I and II regarding important risk factors like diabetes mellitus, arterial hypertension, dyslipidemia and ST-segment elevation myocardial infarction (STEMI). Likewise, there is also a relevant difference regarding the use of myocardial reperfusion strategies (including PCI, fibrinolysis or myocardial revascularization surgery). This way, group I apparently had higher ischemic risk, but received fewer myocardial reperfusion therapies. This may also compromise the comparative analysis of major clinical outcomes, with equality in the total number of combined adverse events but numerical differences in isolated outcomes, with higher rates of reinfarction, shock and mortality in group I and more hemorrhagic complications and ischemic stroke in group II. Nevertheless, hemorrhage rate was significant higher in group II: 8.5% vs. 20% (p = 0.007). Estimating hemorrhagic risk for patients with ACS is not a simple task, since prognostic indexes present low accuracy, being even more complex in elderly patients. In the Spanish LONGEVO-SCA ( Impacto de la fragiLidad y Otros síNdromes GEriátricos en el manejo y pronóstico Vital del ancianO con Síndrome Coronario Agudo sin elevación de segmento ST ) registry, which included patients older than 80, with 78% of the population being submitted to an invasive strategy, the rate of major bleeding was only 7%. In the analysis of age-related variables such as comorbidities, physical disability, cognitive deficit, frailty and risk of malnutrition, only the Charlson comorbidities index