Geriatric Grand Rounds. Geriatric Grand Rounds. Heart Disease in the Elderly: Pitfalls and Practicalities. Objectives. Conflict of Interest Disclosure

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1 Geriatric Grand Rounds Tuesday, January 22, :00 noon Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital To receive the poster, and handouts via , subscribe to our ing list at our web site Heart Disease in the Elderly: Pitfalls and Practicalities Michelle M. Graham, MD, FRCPC Division of Cardiology, University of Alberta Geriatric Grand Rounds Glenrose Rehabilitation Hospital January 22, 2008 Conflict of Interest Disclosure Objectives Nothing to declare Identify challenges in the diagnosis and treatment of IHD in the elderly Focus on ACS and revascularization Application of evidence (or lack thereof) 1

2 The Elderly (what you already know ) Who Are The Elderly? Fastest growing segment of population Canadians over age 65 will increase by 45% Cardiovascular disease is the leading cause of death (36%) > 50% of deaths are due to IHD Lack of consensus about definition Not a homogenous group of people! Options: - define by fitness and frailty - define by chronological age Diagnosis of IHD in the Elderly Atypical presentations, nondiagnostic ECGs Dyspnea common symptom Limited physical activity - difficult to quantify symptoms Tend to present later and be sicker Look for reversible factors - anemia, thyroid disease, HTN, non-adherence Caring for Elderly Patients CVD is often the first serious illness Important considerations: - decreased reserve - increased comorbidity - polypharmacy - societal issues (isolation, devaluation) 2

3 Caring for Elderly Patients Treatment Goals Tendency to link elderly patients to disability, and deteriorating QOL Some think they are less deserving of aggressive medical therapy Care Gap Different priorities in the elderly First, improve quality of life Then, enhance survival.there are fates worse than dying!.stroke, dementia, loss of independence The Elderly in Clinical Trials The Evidence Gap: Clinical Trials vs Reality > 50% of all CAD trials in the last decade failed to enroll any patient >75 years!! 3

4 Elderly NSTE ACS Patients Registry vs Trial Patients Older (>85 years - 11%) More women Comorbidities (CHF, CVA, CRF) Longer time to ECG (up to 45 min!) 43% non diagnostic ECG (age>85) 80% of pts >75 are high risk (ACC/AHA) Clinical Trials: GUSTO IIb, Paragon A/B, Pursuit, GUSTO IV-ACS Outcomes of NSTE ACS 1 in 10! Pharmacological Management 1 in 100 4

5 Oral Antiplatelet Therapy Use of Oral Antiplatelet Agents ASA 22% RR in prevention of non-fatal MI absolute and relative benefits in populations at highest risk Clopidogrel - 16% of patients in CURE were >75; ARR (2.3%) similar to younger Excess bleeding with dual agent therapy Higher TIMI risk scores or prior revasc more likely to benefit Decrease ASA dose (empiric no elderly data) ASA Clopidogrel < 65 years 85 years 95% 87% 52% 30% GRACE and CRUSADE registries GP IIb/IIIa Inhibitors ACC/AHA Class I in patients undergoing early invasive approach (ie cath) Class IIa in high-risk patients not planned for invasive approach Tirofiban and eptifibatide are both cleared renally!! Trials PURSUIT, ESPRIT, PRISM, PRISM-PLUS GP IIb/IIIa Inhibitors: Bottom Line Relative CV benefits varied Worse outcomes in some, similar benefit in others Greater benefits if normal renal function or given at time of intervention More bleeding increases with number of agents used Transfusion 9% 2 agents, 13% 3 agents 5

6 Use of GP IIb/IIIa Inhibitors Antithrombin Therapy < 65 years 85 years GRACE 34% 12% CRUSADE 45% 13% 65% of patients receive excess doses!!! UFH alterations in body composition and protein levels may result in overestimated doses LMWH anti Xa levels higher in elderly therefore more anticoagulant activity Trials vs. placebo no age subgroup data UFH vs LMWH no age subgroup data Use of Antithrombin Therapy Early Invasive Strategy: For Anyone with an Access Route? Decreases with age LMWH used more often than UFH across all age subgroups Use 40-50% >85 years ACC/AHA for high risk features Very few trial patients >75 (0-8%) or did not report age subgroups TACTICS-TIMI 18 (12.5% >75) 3-fold higher risk of major bleeding 6

7 TACTICS-TIMI 18 STEMI in the Elderly NNT 9 The Elderly in Trials and Registries STEMI: Important Points Pre-hospital delays are common Patients fail to recognize atypical features Further confounding cognitive and socioeconomic factors Mean time onset to presentation 4.7 hours community vs 2.1 hours lytic trials Trials: GUSTO I/IIb/III, ASSENT 2/3/3+, HERO-2 7

8 Outcomes (GUSTO-1) Catastrophic Events Thrombolytics in the Elderly Large clinical trials have demonstrated the benefits of these agents in STEMI Fewer than 10% of all enrolled were >75 As many as 46% of eligible elderly patients do not receive thrombolytics (FASTRAC registry) Highest risk for complications, but potentially have the most to gain Choice of Thrombolytic Therapy Primary PCI Greater benefit of fibrin-specific agents (tpa, TNK) may be offset by more ICH compared to streptokinase TNK+UFH is best studied regimen in the elderly to date Each patient must be assessed individually to compare risk/benefit ratio for therapy Higher rates of coronary patency Less ICH Treatment of choice for shock or when contra-indications to lytics exist Similar or better outcomes compared to thrombolytic therapy 8

9 Primary PCI in the Elderly So when to do Primary PCI? Small trials, meta-analyses and observational studies all favour PCI over lytic therapy Greater benefit with PCI as a function of risk Also evidence for reduced-dose heparin and rescue PCI (Senior PAMI) Only 40% of elderly STEMI pts present to PCI hospitals (US data) Whenever you can!! Availability and time to reperfusion must be considered PCI preferable past 6 hours Beta Blockers Adjunctive Therapies Concern about IV use (BP and HR) Oral doses demonstrate survival benefits seen in patients >75 Evidence from small trials and observational studies But underutilization is widespread! 9

10 ACE Inhibitors Several trials enrolled patients >65, and some up to 80 years (SOLVD, V-HeFT II, Atlas, SAVE, AIRE, HOPE) Treatment benefits seen were similar in older patients Particularly useful if CHF or LV function Statins Secondary prevention (4S, CARE, LIPID) enrolled patients up to 75 years Similar benefits in patients > 65 as compared to younger patients HPS enrolled patients age Benefits similar for <65, 65-70, >70 For patients age RRR 25% Revascularization in the Elderly Revascularization Procedures in Elderly Patients An increasing number of elderly patients are referred for revascularization procedures Early randomized trials of revascularization excluded elderly patients Single series data or extrapolation of data has been required to apply evidence in the elderly 10

11 Risks for CABG Mortality PCI Risks Shock Previous CABG Left Main Stenosis Age (per 5 years) EF (per 5% decline) OR 10.9 OR 2.87 OR 1.62 OR 1.51 OR 1.07 Lower procedural success with age - 84% vs 89% Death 3.8% (age 80+) vs 1.1% (<80) 2-4x risk of MI, stroke, renal failure, vascular complications Ko et al Circulation 1992;86:191 Batchelor et al JACC 2000;36: The Controversy Given the risk of morbidity and mortality associated with CABG surgery in elderly patients and the lack of data on its effectiveness when compared with current medical therapy, perhaps bypass surgery in elderly patients should be reconsidered. MacDonald et al CMAJ 2000;162(7): Evidence for Improved Outcomes TIME: a randomized trial of invasive investigation vs. medical therapy in patients >75 years (n=305, FC II) Improved Quality of life at 6 Months: - General Health, pain, vitality (SF36) - Duke activity score index - Rose score - CCS class Pfisterer et al Lancet 2001;358:951 11

12 TIME: Event Free Survival TIME One-Year Follow-up Proportion without MACE P< Time (Days) 81% 51% Invasive Medical Pfisterer et al Lancet 2001;358:951 50% of medically treated pts ended up with hospitalization for ACS and subsequent revascularization No difference in mortality rates or quality of life outcomes MACE 64.2% medical vs 25.5% invasive JAMA 2003;289: APPROACH APPROACH Data Elements Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease Clinical data collection and outcome initiative All patients undergoing catheterization and revascularization in Alberta since 1995 Age Sex EF Prior cardiac history (MI, CHF) Previous interventions (Thrombolytics, PCI, and/or CABG) Indication for procedure Comorbidities 12

13 APPROACH Outcome Endpoints Patient Population Mortality via Alberta Bureau of Vital Statistics Hospital readmission Cost Quality of life 21,573 patients who underwent a diagnostic cardiac catheterization between Age < 70 years n= 15,392 Age years n= 5198 Age 80 years n= 983 APPROACH:5198 patients years APPROACH: 983 patients 80 years 87.3% 83.9% 79.1% 77.4% 71.6% 60.3% Graham et al Circ 2002;105:

14 Risk Reduction Summary Quality of Life: Improved Outcomes Group Survival (%) Medical PCI CABG <70 (n=15,392) (n=5198) 80 (n=983) ARR (%) PCI CABG NNT PCI CABG Improved functional status Symptom relief Similar benefits even if complications More improvements than younger patients - more symptomatic pre-op - lower expectations Majority return to independent living APPROACH SAQ: QOL SAQ: Treatment Satisfaction Treatment Satisfaction < 70 years years >=80 years RX strategy Medical CABG/PCI EHJ 2006 Quality of Life < 70 years years >=80 years RX strategy Medical CABG/PCI 14

15 Caveats: Revascularization So, good for all-comers? Maybe not. The procedure of choice is a decision based on comorbidities and frailty Patients who are not ideal candidates for CABG could tolerate PCI with good effect Optimized medical therapy should be a priority in all patients Frailty The Edmonton Frail Scale Unrepresented in usual risk assessments A way to formalize the end of the bed test? Medical decision-making may become more transparent UHF grant 2008 for pilot data All pts over age 65 admitted to UAH with ACS Assess ability to predict investigations and outcomes Stay tuned!! 15

16 Conclusions Conclusions Diagnosis and management of IHD in elderly patients is difficult Diminished functional capacity Diminished physiologic capacity Organic, social, psychological problems Absence of EBM A comprehensive integrated strategy to reduce CV risk and IHD events is essential in the expanding elderly population Elderly patients benefit from the same medical therapies as younger patients Elderly patients have improved QOL and survival with revascularization procedures Conclusions Age alone should not be a contraindication to treatment Opportunities should not be wasted! 16