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Cardiovascular Care of Older Adults: Acute Myocardial Infarction

Cardiovascular Care of Older Adults: Acute Myocardial Infarction. Karen P. Alexander MD Associate Professor Medicine Duke Clinical Research Institute Duke University Medical Center Durham, NC. Outline. Understand the presentation of ACS in older adults

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Cardiovascular Care of Older Adults: Acute Myocardial Infarction

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  1. Cardiovascular Care of Older Adults:Acute Myocardial Infarction Karen P. Alexander MD Associate Professor Medicine Duke Clinical Research Institute Duke University Medical Center Durham, NC

  2. Outline • Understand the presentation of ACS in older adults • Safe and effective therapies for ACS in older adults. • Assess likely health outcomes among older adults with ACS • Appreciate the role of discharge planning in optimizing medication safety and return to independent functioning. • Needs for future research

  3. Population Incidence of Heart Disease Cardiovascular Health Study Caucasian Male: 10 year follow up Rate/1,000 Person-Years Age (Yrs) CHD = Fatal and Non-fatal MI, Angina, coronary revascularization REF: Arnold AM, et al, JAGS 2005;53:211-218

  4. Risk Factors for First MIINTERHEART Case- Control Acute MI; 52 countries; >30,000 pts Pop. Attributable Risk 93.9% 87.9% * Old = Men >55 yrs; Women >65 yrs REF: Yusuf et al, Lancet 2004;364:937-52

  5. Age ≥ 85 among the Myocardial Ischemia National Audit Project (MINAP) Registry % ≥ 85 years Year Rosengren EHJ 2012:33:562

  6. MINAP: Final MI Diagnosis AGE AGE Gale, EHJ 2012;33:630-639

  7. 1975/78 (REF) – 1993/95 Worcester Heart Attack StudyOR for In-hospital MortalityControlling for gender, med history, AMI type, complications MI Type Age (yrs) QW NQWMI 55-64 65-74 75-84 ≥85 (REF) 1975/78 1.0 1.0 1.0 1.0 1.0 1.0 Case Fatality = 21% Median Age = 66 yrs 1993/95 0.33* 0.89 0.23* 0.55* 0.48* 0.93 Case Fatality = 11% Median Age = 74 yrs *Significant REF: Goldberg, AJC 1998:82:1311-1317; Furman, J ACC 2001;37:1571-80

  8. Time Trends2003 (REF) – 2011 (MINAP Registry)OR In-Hospital Mortality By Age NSTEMI <55 yrs >85 yrs (2003) 1.9% 31.5% (2010) 0.9% 20.4% Mort. RR 0.89 (0.48-1.34) 0.56 (0.42-0.73) STEMI <55 yrs >85 yrs (2003) 2.0% 30.1% (2010) 1.5% 19.4% Mort. RR 0.72 (0.39-1.25) 0.56 (0.38-0.75) Gale, EHJ 2012;33:630-639

  9. MINAP: NSTEMI In-Hospital MortalityAdj. for Age, DM, HTN, CAD hx, HF, ward (REF: Age <55yr) MEN Adj. Odd Ratio (95% CI) Years Years Gale, EHJ 2012;33:630-639

  10. Mortality and NNT Relationships Efficacy (RRR) Efficacy (RRR) Number Needed to Treat 1 year Mortality* Patient Age (Yrs) *Mortality Estimates based on AMI patients treated in Ontario from 1997-2000 Alter, AJM, 2004

  11. Applying Guidelines Out of the Box Community Trials Benefits Risks Disease Severity Comorbidity 62 69 Age • Do they resemble patients in trials? • Is dosing and delivery of treatment similar? • Do conditions of aging dynamically alter treatment effect? • Do treatment risks outweigh benefits? • Do expected outcomes match desired outcomes? REF: Tinetti, NEJM 2004; 351: 2870-2874

  12. Older Adults: Comorbidity and Dysfunction % of population * Frailty: Fatigue, Slow Gait, Weak Grip, Wt loss >10 lbs, Low Activity Patient Age REFS: JACC 2005;46: 1479-87; CHS J Geront Biol Sci 2001; Canadian Health and Aging

  13. Older Adults: Disability Canadian Study of Health and Aging 9,008 Community Dwelling Seniors Basic (physical) and Instrumental (functional) ADLs REF: Griffith L, et al. Age and Ageing 2010;39:738-745

  14. Frailty Phenotype Features: Weakness, Muscle Wasting, Cognitive Impairment, Depression, Nutrition, Isolation, Low Physical Function, Fatigue Comorbidity (>2 conditions) Disability (>1 ADL) Frailty 66% 25% 27%

  15. Heterogeneity of Aging • Biological Phenotype • Cumulative comorbidity counts • Cognitive Impairment • Disability • Functional Status • Visual and Hearing Impairments • Physiologic Phenotype • ↓ Blood vessel integrity and response to injury • ↓ Vascular Compliance • D-dimer and inflammatory markers increase • Altered Clotting (low platelet turnover) • ↑ Thrombin, Fibrinogen, Factors IX, X Jeanne Calment (Photo Age 113) Lived to 122 years, Arles France REF: http://entomology.ucdavis.edu/courses/hde19/lecture3.html

  16. NSTEMI Unmasking Narrow Reserves • Less resilient to acute disease • Less resilient to drug effects DECLINES OF FUNCTION CHALLENGES TO HOMEOSTASIS Fries, 1981

  17. CAD Limiting Reserves • Cardiac disease was major health limitation • Treatment enables resumption of function CAD Treatment CHALLENGES TO HOMEOSTASIS Fries, 1981

  18. Non-CAD Limiting Reserves CHALLENGES TO HOMEOSTASIS • Underlying comorbidity impairs function • Non-cardiac disease limits survival Fries, 1981

  19. NSTEMI Unmasking Narrow Reserves • Less resilient to acute disease • Less resilient to drug effects DECLINES OF FUNCTION CHALLENGES TO HOMEOSTASIS Fries, 1981

  20. Older Adults (≥75 y) = Special Population Presentation Atypical Yes Under treated (Under studied) Yes Independent risk Mortality Yes Independent risk Bleeding Yes Multiple Coexisting Conditions Yes REF: Anderson J, NSTEMI Guidelines. JACC 2007;50:652–726; Tinetti, NEJM 2004; 351: 2870

  21. Presenting Signs by Age CRUSADE : Signs of CHF NRMI 2-4 : EKG non-diagnostic (RBBB or other) % Population Patient Age

  22. ED Presenting Signs and Symptoms Chart Review from CRUSADE (n=607) All P<0.05 N=468 N=182 *Other: Dizziness, Palpitations, Abdominal Pain, Headache, Altered Mentation Nursing Home: 10 v. 2% (p<0.01) Krashnewski, AHA Outcomes Abs. Submitted

  23. Universal MI Definition • Type I: Spontaneous MI • atherosclerotic plaque rupture with thrombus in one or more of the coronary arteries. • Type 2: Secondary MI • a condition other than CAD contributes to increased myocardial oxygen demand or decreased myocardial blood flow. Thrombus • Type 3: Sudden Death MI • Sudden cardiac death with or without ECG changes or biomarkers can be obtained. • Type 4/5: Revasc MI • Peri-procedural injury associated with instrumentation of the heart during revascularization, either PCI or CABG. TYPE I Procedures Heart Failure TYPE 2 Anemia Renal Failure Tachyarrhythmia REF: Thygesen K, JACC 2007;27:2173-95

  24. I I I I I I IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III I I I I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I I I I IIa IIa IIa IIa IIa IIa IIa IIa IIb IIb IIb IIb IIb IIb IIb IIb III III III III III III III III A B 2011 UA/NSTEMI Guidelines : Special Population Section • Older adults with UA/NSTEMI should be evaluated and treated for acute and discharge therapies in a similar manner as younger adults • Attention should be given to adjusting anti-platelet and anticoagulant doses based on weight and renal function (eg. estimated creatinine clearance) in older adults. • Decisions on management of older adults should not be based solely on chronologic age but should be patient-centered, with consideration given to general health, functional and cognitive status, comorbidities, life expectancy, and patient preferences REF: Circulation. 2011;123:000-000.

  25. NSTEMI – Case

  26. I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III B Older Adults: Conservative v. Invasive Older patients face increased early procedural risks with revascularization relative to younger patients, yet the overall benefits from invasive strategies are equal to or perhaps greater in older adults. REF: Anderson J. J Am Coll Cardiol 2007;50:652-726

  27. Event Rate (%)OR Cons. Inv. (Inv v. Cons) 4.8 5.0 1.07 9.1 7.6 0.82 10.3 7.8 0.73 21.6 10.8 0.44* Age Group(n) ≤55 y (716) 56-65 y (614) 66-75 y (612) ≥75 y (278) 0.5 0 1 1.5 2.0 Invasive Better Conservative Better Older Adults: Benefit of Invasive Care (TACTICS TIMI 18) NNT = 67 NNT = 9 * P <0.016 DEATH or MI at 6 mo Source: Bach AIM 2004; 141:186-195

  28. NSTEMI – Case Creatinine 1.0 mg/dl Creatinine 1.0 mg/dl Weight 238 lbs Weight 108 lbs *Based on Heparin 60 U/kg bolus and 12 U/kg infusion, cap 4000/1000 and Integrilin reduced infusion dose if CrCl <50ml/min

  29. I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III B 2011 UA/NSTEMI Guidelines : Special Population Section • Attention should be given to adjusting anti-platelet and anticoagulant doses based on weight and renal function (eg. estimated creatinine clearance) in older adults. REF: Circulation. 2011;123:000-000.

  30. Excess Antithrombotic Dosing Avoidable Risk REF: Alexander KA, JAMA 2005

  31. NSTEMI – Case *Based on Heparin 60 U/kg bolus and 12 U/kg infusion, cap 4000/1000 and Integrilin reduced infusion dose if CrCl <50ml/min

  32. CRUSADE Bleeding Score REF: Subherwal S. The Crusade Bleeding Score. Circulation 2009;119: Epub

  33. REF: Subherwal S. The Crusade Bleeding Score. Circulation 2009;119: Epub

  34. Major Bleeding with Antithrombotic therapy Unavoidable Risk • ≥2 Antithrombotics (anti-platelet [aspirin or clopidogrel], anti-coagulant, or GP IIb/IIIa; n=50,969; c-index 0.72) • <2 Antithrombotics (anti-platelet, anti-coagulant, or GP IIb/IIIa; n=5,931; c-index 0.73) REF: Subherwhal, Circ 2009;119: 1872-1882

  35. Therapeutics in ACS Among Patients >90 Years Old Mortality Major Bleeding Optimal Even among oldest old – better outcomes with better adherence to ACC/AHA Guidelines (1) Acute Aspirin, (2) Acute Beta-blockers, (3) Acute Heparin, (4) GP IIb/IIIa inhibitors with PCI, (5) Cardiac Catheterization <48 hours - Skolnick et al, JACC 2007

  36. P=0.001 P<0.001 16.5 12.3 P=0.033 P=0.010 P=0.007 P=0.001 P=NS 6.7 6.6 P=0.006 6.1 5.5 5.7 4.2 4.3 4.2 3.0 1.7 N=2240 N=2052 N=2121 N=1376 Patient Age ACUITY: Major Bleeding in PCI CohortStrategy Matters NNT to prevent one major bleed Age <55 – NNT 38 Age >75 – NNT 16 % Major Bleeding Events REF: Lopes JACC 2009 Excluding CABG-related bleeding

  37. Quality of Care for Hospitalized Elders and Post-Discharge Mortality 6,392 Vulnerable Elderly Patients identified a using VES-13 Survey One year mortality based on adherence to Geriatric ACOVE Measures ACOVE Quality of Care above Median = 18% reduction in 1 year death Discharge Planning Assess Nutrition Assess Cognition Assess Mobility Mobility intervention Delerium Management Pressure Ulcer Management REF: Aurora JAGS 2010;58: 1642-1648

  38. Quality of Care for Hospitalized Elders and Post-Discharge Mortality 6,392 Vulnerable Elderly Patients identified a using VES-13 Survey One year mortality based on adherence to ACOVE Measures ACOVE Quality of Care above Median = 18% reduction in 1 year death REF: Aurora JAGS 2010;58: 1642-1648

  39. MI – Discharge

  40. Discharge: Take-off and Landing • Successful Outpatient visit plan • Early Follow up Appointment (Cardiology or Medicine) • Successful communication • Return to Independent Function • Consider caregiver support, home safety • Avoid Complications, Rehospitalization • Medication Review, Education, Simplification • Symptom Education • Clear Contact Information

  41. Cardiac Rehab and Survival In Older Cardiac Patients Cardiac Rehab Participation = 21% to 34% lower Mortality >600,000 Medicare Beneficiaries (ICD-9: AMI, ACS, Stable CAD, CABG, PCI) 70,040 Propensity Matched Pairs; Regression Modeling; Instrumental Variable Analysis REF: Suaya JA et al, JACC 2009;54:25-33

  42. 2011 UA/NSTEMI Guidelines : Special Population Section • Consideration should be given to patient and family preferences, quality-of-life issues, end-of-life preferences, and sociocultural differences in older patients with UA/NSTEMI. I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III C REF: Circulation. 2011;123:000-000.

  43. “What are the most important goals from the treatment of your heart disease?” N=626 % Reporting in Top 3 Patient Age REF: Alexander ACC Abstract

  44. STEMI Reperfusion REF: Bueno, EHJ 2010;54:25-33

  45. Chronologic age ≠ biologic age Age 75 is cut point for altered paradigm of care Comorbidities, altered physiology, function alter risk/benefit Treatment recommendations similar…. Avoid errors of omission and commission Dosing and delivery matter…perhaps more Avoid hazards of hospitalization, transitions of care Extending EBM to personalized care … More representative trials Best practice recommendations Explicit discussions of patient goals for treatment Transitions of Care, Goals of Care Conclusions

  46. Cardiologist Older Adult COMORBIDITY COMPLICATIONS OUTCOMES Corinth Canal: Isthmus 5 miles long between Greece and Peloponnesus

  47. Future Directions • Advance Science • Adding Key data elements to large registry work • Comorbidity: non-cardiac issues that alter cardiac management • Physiology (Vascular Stiffness, HF NEF, Sinus node dysfunction) • Genetics (Telomere length, genetic aging) • Advance “Best Practice” and systems research • Drug Safety • Care models, collaboration • Transitions of care • Broaden perspectives on goals of care • Functional Status and recurrent procedures

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