ACUTE CORONARY SYNDROME PCI IN THE ELDERLY G.KARABELA MD.PhD ATHENS NAVAL HOSPITAL INTERVENTIONAL CARDIOLOGY DEPARTMENT
NO CONFLICT OF INTEREST TO DECLAIRE
Risk stratification in Αcute Coronary Syndrome. Rev Esp Cardiol. 2014;67(7)
Randomized trials have enrolled patient populations much younger than those observed in clinical practice. EUROP H J 2012;1:143 HEART 2012;98
Elderly pts account only for a disproportionately small number of the studies population Patients above 75 years of age comprise only 9% of clinical trial populations only about 50% of trials enroll patients above the age of 75. Approximately 33% of all ACS episodes occur in patients over 75 years account for about 60% of overall mortality due to ACS. Thus, information is sparse to guide the care of this high risk ACS subset. J Am Coll Cardiol. 2005;46 Ann Intern Med. 2002 Mar5
Increasing age does not imply only more years, but also a change in the overall characteristics The proportion of women increases from < 30% when a study population has a mean age of 60 years to 63 years (as in most RCTs) to 50% in study populations with a mean age of 80 years. Elderly populations will also have > 70% hypertensive patients > 35% Diabetics 20% with an estimated (egfr) < 60 ml/min more patients with prior myocardial infarction (MI), stroke, or with atrial fibrillation and peripheral arterial disease. Eur Heart J. 2011;32:51 JACC 2012;5:906 16.
REVASCULARIZATION THERAPY STEMI
Thrombolysis vs. ppci-gusto IIb trial. was one of the first to report that PCI is superior to fibrinolysis. RR of the primary composite end point of death, reinfarction, or stroke at 30 days of 13.6% vs.54% 0.67 CI (0.47-0.97) P=0.022 Elderly pts benefit most De Boer et al. JACC 2002
METAANALYSIS INCLUDED 10 TRIALS THROMBOLYSIS VS. ppci THE 30 DAYS MORTALITY IN PTS >70 WAS HALVED IN PCI GROUP (odds: 9.2 vs. 18.7 p=0.002) E HEART J 2002;23:550-557
Key studies of primary PCI in the elderly and very elderly with STEMI. TRIANA Western Denmark Heart Registry SENIOR PAMI PCAT-2
PRIMARY VS. FIBRINOLYSIS IN VERY OLD PTS WITH STEMI TRIANA STUDY: (death, re -infarction, stroke in 30 days) mean age:81 year Eur Heart J. 2011
Western Denmark Heart Registry From 2002 to 2009 all consecutive patients 80 years with STEMI treated with PPCI 1,322 elderly (1,213 octogenarians and 109 nonagenarians) 30-day mortality was 17.2% vs 25.8% ( P = 0.028), 1-year mortality was 27.6% vs 32.5% ( P = 0.18) and 5-year mortality 53.6% vs 57.3% ( P = 0.087), respectively. Adjusted 30-day hazard ratio (HR) = 1.59, 1-year HR = 1.34, and 5-year mortality HR = 1.39 was higher in nonagenarians compared with octogenarians. Catheter Cardiovasc Interv. 2013;81 (6) 912
SENIOR PAMI -largest RCT for elderly undergoing PPCI vs TT -- 481 patients >70 yrs Among patients 70 to 80 years old, there was a nonsignificant 38% reduction in death, a nonsignificant 36% reduction in death/cerebrovascular accident, and a statistically significant 55% reduction (11.6% vs. 18.0%, P = 0.005) in the combined end point of death/cerebrovascular accident/reinfarction at 30 days. Among those older than 80 years, there was no advantage of one strategy over the other. Grines, C. L. SENIOR PAM
Meta-analysis of 22 randomized trials PPCI vs. Fibrinolysis 410 octogenarians of the 6763 patients studied Octogenarians undergoing PPCI had a lower incidence of all-cause mortality (18.3% vs. 26.4%, P = 0.04) at 30-day follow-up compared to those who were thrombolysed. Patients with high mortality risk scores benefited most from PPCI Am Heart J. 2011;161: 500-507
REVASCULARIZATION THERAPY UA-non STEMI
Patients aged 75 years represent approximately 40% of those with NSTEACS. Eur Heart J Acute Cardiovasc Care. 2012;1
The Effect of Routine, Early Invasive vs. conservative management on Outcome for Elderly Pts with NonSTEMI TACTICS TIMI 18 TRIAL 2220 patients assigned to an early invasive or conservative management strategy <55 years >55 to 65 years >65 to 75 years > 75 years The primary end point was the combined incidence of death, MI, rehospitalization for an ACS at 30 days and 6 months Ann Intern Med. 2004;141:189-95
TACTICS TIMI 18 TRIAL Odds ratios for death, nonfatal MI, death or nonfatal MI, and death, MI, or rehospitalization absolute reduction of percentage points (5.7% vs. 9.8%; P 0.019) and a relative reduction of 44% in the composite incidence of death or nonfatal MI at 30 days, as well as an absolute reduction of 4.8 percentage points (8.8% vs. 13.6%; P 0.018) and a relative reduction of 39% at 6 months. Ann Intern Med. 2004
Effects of age on long-term outcomes after a routine invasive strategy vs a selective invasive strategy in pts with nonstemi - a metaanalysis from the FRISC II - ICTUS - RITA-3 (FIR) trials. 5467 pts <65 years 65-75 >75years 2807 1811 839 (51.3%) (33.3%) (33.3%) main outcome: The 5 years death or MI Heart 2012;98:207e213
Meta-analysis from the FRISC II - ICTUS - RITA-3 (FIR) trials. the routine invasive strategy was associated with a lower hazard in those aged 65-74 years unadjusted HR 0.72, 95% CI (0.58 to 0.90), p<0.003 >75 years unadjusted HR 0.71, 95% CI (0.55 to 0.91), p.0.007 but not in men aged <65years for interaction. Unadjusted HR 1.11, 95% CI (0.90 to 1.38), p<0.33 Heart 2012;98:207e213
Early Aggressive Vs. Initially Conservative Treatment in Elderly Patients With NonSTEMI The Italian elderly ACS 313 patients 75 years of age (mean 82 years) primary endpoint composite of death, MI, stroke, and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year. J Am Coll Cardiol Intv. 2012;5(9)
The Italian elderly ACS The primary endpoint was significantly reduced in pts with elevated troponin on admission (HR: 0.43; 95% CI: 0.23 to 0.80), but not in those with normal troponin (HR: 1.67; 95% CI: 0.75 to 3.70; p for interaction 0.03). JACC Cardiol Interv. 2012;5(906-16)
The Italian elderly ACS 1-Year Rates of Primary Endpoint According to Treatment Strategy in patients with normal (A) or elevated troponin levels (B) at trial entry Am Coll Cardiol Intv. 2012;5(9)
European Heart Journal 37, 3:.267-315
in conclusion Approximately 33% of all ACS episodes occur in patients over 75 years In STEMI ACS, primary PCI offer a clinical advantage over fibrinolytic therapy, not only does it provide important diagnostic information regarding the patient s symptoms, but it also decreases the risk of major bleeding associated with fibrinolysis. In non STEMI ACS, a routine early invasive strategy seems to reduce death or nonfatal MI among elderly patients, after careful evaluation of potential risks and benefits. In addition, the use of clopidogrel, rather than newer agents, the use of bivalirudin rather than unfractionated heparin and a IIb/IIIa inh and the transradial approach to PCI reduces bleeding complications and improves outcomes.