Coronary artery disease intervention considerations in elderly patients

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
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Patient Case




83 year old male, small NSTEMI, moderate
LMCA, 3 vessel disease, AAA, moderate
MR, chronic atrial fibrillation, diabetes

How to proceed?
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(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
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Complex Trade-offs





Clinical Questions:
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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?
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Goals of Coronary

Revascularization

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
(USA)
13
60
80
5
34
41
0
20
40
60
80
100
US Pop. %Total MI
%Total MI
Deaths

%
Age 65+

Age 75+
CVD Intervention at Vietnam
National Heart Insitute
(to 5/2013)
16671
11130
6648
2624
3283
1373
4821
2845
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
CĐMV
Can thiệp
ĐMV
NVHL TTOL
Can thiệp

TBS
TD ĐSL Ablation
Cấy máy
TNT
Source: VNHI
Percutaneous Coronary Intervention (PCI)
163
153
208
164
231
538
802
1225
1622
1822
2120
2142
2476
2978
95
134
165
297
461
719
794
988
1042
1368

1406
1611
2050
0
500
1000
1500
2000
2500
3000
3500
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
CĐMV Can thiệp
Soource: VNHI
The Magnitude of PCI in Older Persons
at VNHI (%)

0
10
20
30
40
50
60
< 65 65 and older 75 and older 80 and older
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Older CV Patients are “Different”


Reduced cardiovascular reserve

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•

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Decreased vascular compliance

Increased myocardial stiffness

-adrenergic responsiveness + impaired sinus node
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Higher burden of comorbid illness
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“frailness”
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Altered pharmacodynamics and
pharmacokinetics
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•
Decline in creatinine clearance, hepatic metabolism

Altered volume of distribution (adipose tissue)
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•
Altered clotting mechanisms

Reduced stem cell repair
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•
Amyloid angiopathy
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Platelets
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Turn over slower; older platelets are less „sticky‟
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•
t-PA release enhanced with age (desmopressin)
↑ Thrombin generation with age
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↑ Fibrinogen, ↑ Factors IX/X
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Altered Hemostasis and

Inflammatory Markers


↓ Blood vessel integrity and response to injury
D-dimer and inflammatory markers increased with
age, and frailty

J Thrombosis and Hemostasis, Lakatta Circ 2003,
Gudnason JThrombosis and Hemostasis
Issues in the management of the
Elderly Patient with coronary disease
Under utilization

Under utilization

- side effects

- cost
of

of
diagnostic testing

medications
Lower rates of revascularization

Higher complication rates with invasive
procedures
Comorbidity
Disease Severity
Challenges in Evidence Based Medicine
60



Age
68.3
Karen Alexander, DCRI
Advanced CAD
Elderly
Community

Trials

Guidelines
Excessive Dosing of Anticoagulants by Age
70
64.5
42% of patients got excess
60


50
38.5
37
40
33.1
28.7
30
16.5
20


10
12.5 12.5
8.5
0
LMW Heparin

< 65 yrs
UF Heparin GP IIb/IIIa
65-75 yrs >75 yrs

Alexander JAMA 2005;294:3108-3116
% Excessive Dose
Mechanisms Leading to Pharmacokinetic
Variations of Drug Effects in Elderly
JACC 2010;56:1683-92
TRITON-TIMI 38: Net Clinical Benefit
Bleeding Risk Subgroups
Risk (%)
Prior
Stroke / TIA
Yes
No
+ 37
-16
P = .006
int
-1
75
Age
-16
P
int
= .18
<75
<60 kg

≥60 kg
+3

-14
Weight
P
int
= .36
-13
OVERALL
0.5 1

HR
2
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