Coronary artery disease intervention considerations in elderly patients

Coronary Artery Disease Intervention Considerations in Elderly Patients A/Prof.. Surgeon – CABG General Cardiologist – medication Patient - Are they even in the decision making proce

Coronary Artery Disease

Intervention Considerations

in Elderly Patients

A/Prof Phạm Mạnh Hùng, MD.FACC.FESC

Director Cardiac Cath.Lab – Vietnam Heart Institute

Secretary General – Vietnam Heart Association

PCI

(CAD) Interventionalist – PCI;

(AAA) Stent Graft?

Surgeon – CABG

General Cardiologist – medication

Patient - Are they even in the decision making process??

Cor Angio

Treatment Methods Selection

• Medical ?

• Surgery?

• Intervention?

To intervene or not???

Coronary disease AAA

Optimal medical therapy?, PCI ?, DES/BMS?, CABG?

1, 2, or 3 vessel, LMCA involvement and % stenosis?

Anatomy suitable – SYNTAX Score?

Severity of ischemia?

Diabetic?

LV function and concomitant valvular disease?

Other co-morbidities?

Prior PCI or CABG?

Potential future elective non-cardiac surgery?

Patient ability for maintaining clopidogrel adherence?

Positively impact longevity/mortality

Improvement in health status/symptoms Ability to influence either is not equal for all clinical scenarios

Longevity gains limited to selective

patient scenarios - PCI vs CABG

The Magnitude of CVD in Older Persons

Percutaneous Coronary Intervention (PCI)

The Magnitude of PCI in Older Persons

•

Older CV Patients are “Different”

Reduced cardiovascular reserve

•

•

•

Decreased vascular compliance

Increased myocardial stiffness

-adrenergic responsiveness + impaired sinus node

• Higher burden of comorbid illness

Altered clotting mechanisms

Reduced stem cell repair

• ↑ Fibrinogen, ↑ Factors IX/X

•

J Thrombosis and Hemostasis, Lakatta Circ 2003, Gudnason JThrombosis and Hemostasis

Issues in the management of the Elderly Patient with coronary disease

Lower rates of revascularization

Higher complication rates with invasive procedures

Excessive Dosing of Anticoagulants by Age

Mechanisms Leading to Pharmacokinetic

Variations of Drug Effects in Elderly

JACC 2010;56:1683-92

TRITON-TIMI 38: Net Clinical Benefit

Bleeding Risk Subgroups

P int = 006

-1

75 Age

Prasugrel Better Clopidogrel Better

Wiviott SD, et al N Engl J Med 2007

Procedure Use as a Function of Age

- Alexander, JACC 2005

Invasive Procedures in the Elderly:

NCDR in USA 2010-2011

n= 941,248 n= 1,110,150

JACC 2012;60:2017-31

Effect of Age (65-75 and > 75) on PCI mortality

Data from our center (VNHI)

(patients with PCI)

Patients >75 years have

more extensive coronary

PCI Features: >75 versus <75 years

Complications: Age >75 versus <75 years

• Any procedural complication:

8.5% (vs 5.1%)

• Major bleeding: 3.5% (vs 1.9%)

• Blood transfusion: 6.8% (vs 3.3%)

40 40-59

69-79

80 Age

Years

Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26

Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26

Risk-adjusted in-hospital mortality

Age >75 vs Age <75

OR = 2.4 (95% CI 2.27-2.44)

Risk adjustment variables: STEMI, cardiogenic shock, prior CHF, prior Valve, CVD, PVD, Prior PCI, PreIABP, EF, corles50, preTIMI, diabetes, Lesion SCAI, BMI, GFR, dialysis, NYHA 4, highest risk lesion

segment, PCI status, race and gender

Effects of Aging on Ventricular Function

Filling more dependent on atrial Prolonged time of relaxation

Lower EF Lower cardiac output

Paclitaxel-Eluting Stent Outcomes

in the Elderly

Circ Cardiovasc Intervent 2009;2:178-187

TIME: Randomized trial of Invasive vs Medical Therapy

Age > 75 yrs, chronic angina

Lancet 2001; 358: 951-957

Benefit of an Invasive Strategy in NSTEACS:

Greatest in patients > 65 years of age

Complications after Primary PCI

0.9 0.8

30-day Mortality Rates in Medicare

CABG Population: PTCA Vs

Pooled Analysis of 10 Randomized

trials of CABG versus PCI (BMS

PTCA)

or

 No difference mortality or death / MI at 5 years

Favors CABG Favors PCI

Lancet 2009;373:1190-1197

Revascularization in the Ultra-Elderly

 Revascularization appears to improve outcomes in

elderly patients with stable angina (PCI or CABG), ACS (PCI or CABG) and STEMI (PCI)

 Complications of PCI and CABG are greatly increased

as age increases (bleeding, renal failure, CHF, CVA, Stroke)

- Select patients most likely to benefit

- Use strategies to avoid CVA and renal failure

- Radial access and/or bivalirudin to reduce bleeding

Pre PCI angio

Post - PCI

Thanks