Interventions in the Elderly

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1 Interventions in the Elderly Satya Reddy Atmakuri MD FIFTH ANNUAL SYMPOSIUM

2 I Have No Financial Interest to Disclose

3 People greater than 65 years of age will increase from 12% of population in 2000 to 20% of population in 2030 People greater than 85 years of age will increase from 9.3 million in 2000 to 19.5 million in 2030 Average life expectancy in US was 77.3 years in 2002 and rising We take care of these elderly patients every day We are in Mesa!!

4 Acute coronary syndromes ST elevation myocardial infarction Peripheral arterial disease Structural heart disease

5 Chest pain (cardiac) greater than 20 minutes Abnormal cardiac enzymes ST-T segment changes

6 Copyright American Heart Association, Inc. All rights Figure 1. Representation of the subgroup 75 years of age as a proportion of the total trial and community populations described in the present statement. Alexander K P et al. Circulation. 2007;115:

7 Figure 2. Proportion of age subgroups with cardiac risk factors and comorbidity from the CRUSADE Quality Improvement Initiative. Alexander K P et al. Circulation. 2007;115:

8 Copyright American Heart Association, Inc. All rights Figure 4. Admission signs, symptoms, and initial diagnosis according to age groups from NRMI (Chest Pain, Cardiac Dx) and CRUSADE (Signs of CHF). Alexander K P et al. Circulation. 2007;115:

9 Copyright American Heart Association, Inc. All rights Figure 5. In-hospital and 30-day death rates according to age groups in trial (VIGOUR) and community (GRACE) populations. Alexander K P et al. Circulation. 2007;115:

10 Figure 7. Benefit of invasive care in older patients in reducing the risk of death or MI combined from the TACTICS-TIMI 18 trial.117. Alexander K P et al. Circulation. 2007;115: Copyright American Heart Association, Inc. All rights

11 Patient Presentation - ACS 91 yo gentleman presents with progressive class III IV angina Able to walk 1-2 blocks 2 months prior to presentation Cardiac risk factors Hypertension Hyperlipidemia Sick sinus syndrome s/p PPM Rheumatoid arthritis

12 Stress study Ischemia of anterior/anterolateral walls and apex EF 45% Echocardiogram EF 40-45% No significant valvular disease Medical therapy Atenolol 25, Lisinopril 2.5, Imdur 30 ASA 81, Simvastatin 10 Admitted to the hospital with worsening angina and dyspnea at rest New onset CHF

13 Coronary Angiography

14 PTCA 3mm balloon at 8 atm Impella 2.5 CO 2.2 L/min at P8 7 Fr EBU 3.5 guide Runthrough wire in LAD BMW wire in LCX

15 Stent 4x20mm Promus Premier

16 Final Angiogram IVUS: LAD 9.4mm2; LM 12.2mm2

17 Figure 1. Representation of elderly ( 75 years of age) trial versus community populations. Alexander K P et al. Circulation. 2007;115:

18 Copyright American Heart Association, Inc. All rights Figure 2. Presentation of STEMI and age (NRMI 2 4). Alexander K P et al. Circulation. 2007;115:

19 Copyright American Heart Association, Inc. All Figure 3. Reperfusion therapy for STEMI (NRMI 2 4). Alexander K P et al. Circulation. 2007;115:

20 Figure 4. Death and stroke after fibrinolysis in GUSTO-I, categorized by age. Alexander K P et al. Circulation. 2007;115: Copyright American Heart Association, Inc. All rights

21 Copyright American Heart Association, Inc. All rights STEMI Figure 5. Fibrinolytic therapy and age (excluding patients presenting beyond 12 hours, with normal ECGs, with only T-wave inversion or ST depression). Alexander K P et al. Circulation. 2007;115:

22 STEMI Fibrinolytic vs. PCI (PCAT data) Alexander K P et al. Circulation. 2007;115: Copyright American Heart Association, Inc. All rights

23 Shock trial Small subset, n=56 No benefit from revascularization Shock registry 277 patients > 75 years Benefit with early revascularization

24 81 year old female Risk factors Hypertension Hyperlipidemia Severe COPD FEV L Current smoker Presentation 3 hours of chest pain Inferior ST elevation by EKG

27 Placement of two drug eluting stents

28 Patient developed COPD exacerbation Intubated on hospital day 3 Ventilator associated pneumonia Atrial fibrillation GI Bleed CVA Tracheostomy Passed away from multi-organ failure after 40 days from presentation

29 Developed to treat patients High surgical risk (Partner Cohort-A) In-operable (Partner Cohort-B) Technically difficult Porcelain Aorta Radiation Sternal infection Patent LIMA underneath sternum

30 Co-morbidities STS Euro-score Disability ADLs Dementia Wheel-chair bound Frailty

Frailty - Risk Assessment in Elderly Syndrome of multisystem impairment associated with aging that results in decreased physiologic reserve and increased

31 Frailty - Risk Assessment in Elderly Syndrome of multisystem impairment associated with aging that results in decreased physiologic reserve and increased vulnerability to stressors. Increasing age Fried J Gerontol A Biol Sci Med Sci Mar;56(3) figure modified from Taffert GE: Physiology of aging

32 Objective Frailty Assessment - Physical Frailty in CHS Self Report Unintentional weight loss Subjective exhaustion Low physical activity Objective Measures Slow walking speed Low grip strength Frailty increases risk for Death New disability Major complications after cardiac surgery Resource utilization Fried 2001, Guralnik 2000, Studenski 2011, Afilalo, 2010.

33 Frailty in the general population 3 year Outcomes (%) Frailty Status at Baseline (n) Died First Hospitalization First Fall Worsening ADL Disability Worsening Mobility Disability Not Frail (2469) Intermediate (2480) Frail (368) 7% p value < < < < < Fried, LP. J Geront Med Sci 2001, 56A, 3, M146

34 Frailty Score in Transcatheter Valve Frailty Domain Measure Frailty Score Slowness 15 foot walk gait speed (m/s) Quartiles (0-3) Weakness Grip strength (kg) Gender based quartiles (0-3) Wasting and malnutrition Inactivity Serum albumin (g/dl) Quartiles (0-3) Katz ADLs (dress, bath, transfer, feed, toilet, continence) Score range = most frail 0 = least frail Any dependence=3, Independence=0 J Am Coll Cardiol Intv. 2012;5(9):974

35 Unadjusted Clinical Outcomes J Am Coll Cardiol Intv. 2012;5(9):974

36 Frailty: Increased mortality after TAVR J Am Coll Cardiol Intv. 2012;5(9):974

37 Frailty: Increased mortality after TAVR Frailty Futility 78% of frail subjects alive at 1 year J Am Coll Cardiol Intv. 2012;5(9):974

38 94 year old female Presents with Class III CHF STS 11.2% Normal coronaries Normal LV function PAD Balloon Aortic Valvuloplasty 1 year ago Frailty score After valvuloplasty 3 Current presentation - 7

39 Vmax 3.7m/sec after BAV now back to 4.18m/sec ; mean gradient 45 mm HG Area-0.8cm 2 Heavily calcified valve

42 Edwards-Sapien 26mm valve

44 At 6-month follow up NYHA Class II Frailty score back to 3 Lives independently

45 Safety of Contemporary Percutaneous Peripheral Arterial Interventions in the Elderly 7,769 pts from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium PVI registry. Procedural success is lower in elderly pts ( 80 years) than in younger groups (70-80 years and < 70 years): 74.2% vs. 78% vs. 81.4%, respectively; P < 0.001) In multivariate analysis, advanced age predicts increased vascular access complications However, very old age is not associated with significantly higher in-hospital mortality, MI, stroke, or reintervention Implications: Contemporary peripheral vascular intervention can be performed in elderly patients with low rates of periprocedural complications. Plaisance BR, et al. J Am Coll Cardiol Intv. 2011;4:

46 85 year old practicing attorney presents with chest pain and right foot pain and noted to have troponin 2.4 DM HTN Hyperlipidemia CAD s/p CABG in 2000 CRI with creatinine in 1.8 to 2.0 range Initial medical management NTG, iv heparin ASA, beta blocker, statin

47 Physical Exam Clear lungs, S4, 1/6 SEM, R carotid bruit Left toe ulcer and non-palpable pulses in left foot Chest discomfort improved with medical therapy ABI Right 0.72; Left 0.4 Carotid ultrasound Right > 80% stenosis; Left < 50% stenosis Echo EF 55-60%, Aortic sclerosis

49 Placement of two drug eluting stents

50 Stent placement in the left external iliac artery

51 Placement of stents in left SFA

52 Atherectomy and Angioplasty of left anterior tibial artery

53 Atherectomy and Angioplasty of left anterior tibial artery

55 Cardiac No angina Stress study in 2011 No ischemia, EF 60% Lower extremity No claudication (ABI in 2013: R 0.9, L-0.8) R toe partial amputation; healed well No further ischemic sequalae Carotid Widely patent stent in 2013 Renal Creatinine 2.2

56 Patients > 75 years : Are usually not enrolled in clinical trials Present with atypical symptoms Have more co-morbidities Have more risks associated with interventions Have the greatest benefit

57 75 year old female presents with severe dyspnea, orthopnea, PND Hypertension Hyperlipidemia COPD Multiple admissions for COPD exacerbation over the last three months EKG Diffuse ST depression in anterior leads CXR COPD changes, pulmonary edema Labs Troponin 2.69

Prospective Evaluation of the Eyeball Test for Assessing Frailty in Elderly Patients with Valvular Heart Disease

Prospective Evaluation of the Eyeball Test for Assessing Frailty in Elderly Patients with Valvular Heart Disease Background Frailty is a common occurrence in elderly patients Approximately half of the