heart disease and the aging...
TRANSCRIPT
Heart Disease and the Aging Population
Rudy Chow
UBC Division of Cardiology and Geriatrics
OUTLINE
Scope of the Problem
• As more baby boomers age, growing number of
older adults has created major
demographic imperative
• US (2010‐2050) # > 65 years expected
to double from 40 million to > 80
million
• One of fastest growing segments
of population is individuals >85
• Expected to more than triple
over
same period
PROJECTED PERCENTAGE OF CANADIAN POPULATION OVER THE AGE OF 75
Portion of working‐age
population declined to
66.5% from 68.5%
Portion of working‐age
population declined to
66.5% from 68.5%
• Huge population shift is of particular significance aging
= most potent risk factor
for CV diseases
• Older patients already make up 60%
of all CV pts
Impact of age and the heart?
• CV disease = disease of aging
• CAD, HTN, stroke, arrhythmias, valvular
disease all become more common with each passing decade
Why?
•Fundamental biological changes
•Cumulative effects of lifestyle
•Comorbidities
AGE RELATED CHANGES…
Stiffness
Thickness/size
Loss
Age‐Associated Changes in the
HeartClinical Consequences
↑ Collagen, changes in elastin, ↑
left ventricular wall thicknessImpairs passive left ventricle
filling
Prolonged availability of
intracellular calciumDiastolic dysfunction
↑ Left atrial size ↑ Susceptibility to atrial
arrhythmias
↓ Number of pacemaker cells in
sinoatrial node↓ Ability to elevate HR in
response to exercise
↓ Sensitivity to β‐adrenergic
receptor stimulationImpaired ability to ↑
heart rate
and contractility in exercise
Recent Decade, Expanded
Armentarium…
Recent Decade, increased
procedures
PROBLEMS we see
• Despite technological advances….
• Risk of both medication‐related adverse events and procedural complications remains
high among older adults
POLYPHARMACY
• Concurrent use of multiple medications increases potential for
adverse drug reactions
• Age‐related pharmacokinetic changes – many elderly renal impairment
• Compliance
with medication regimens may decrease
– BID regimens– NTG patch– Hydralazine (QID?)– Metolazone (30 mins before)
• Patients may be treated by multiple physicians
• May be prescribing drugs without knowledge of other medications the patient is taking
– Medication reconciliation
– Pharmanet
– Bring in your meds
Procedural Complications
• Estimated Octogenarians
represent 12% of the cath lab referral base
• Challenges: – Bleeding risks– Higher rates of co‐
morbidities– Renal dysfunction CIN– Supine position – chronic
back pain
<65 >75 P
value
Hematoma 1.5 2.4 0.073
Pseudoaneurysm 0.9 2.4 0.29
Retroperitoneal
bleed0.4 1.2 0.14
Transfusion 1.6 3.0 0.02
Procedural complications
DEMENTIA
Eur J Heart Fail 2007;9:440‐9.
• Lower tolerances to sedation
– oops too much
diazepam
• High risks for procedural and post
procedural complications
• Issues surrounding consent
Ann Intern Med 2004;141: 186‐95Ann Intern Med 1998;128:194‐203Stroke 2001;32:1508‐13. JAMA 2013;310:2078‐85.
• Typical patients routinely present with coexisting
geriatric syndromes that affect health care goals, care processes, and
outcomes
• Should we do this?• Do they want this?• How can we do this
safely?
ARE WE REDIRECTING OUR RESOURCES TO THE WRONG GROUPS?
Who Stands to gain from a medical intervention?
Case 1 – SOB in the ER• 82M DM2, HTN, otherwise
independent brought in by EHS with SOB and confusion
• Troponin T 36 100• Now symptom free
A) Admit to 5A and treat medically
B) Admit to CCU and refer for cath
C) Admit to CTU and treat medically
D) admit to CTU and treat for noncardiac etiologies
Prevalence of myocardial infarction by age and sexPrevalence of myocardial infarction by age and sex
Prevalence of Myocardial InfarctionPrevalence of Myocardial InfarctionNational Health and Nutrition Examination Survey: 2009–2012.
Atypical symptoms
• Occur more among elderly
patients with NSTE ACS
• GRACE• avg age with atypical
sx’s 72.9 yrs• typical sx’s 65.8 yrs
• 40% >85 yr had CP on
presentation– c/w 77% of those <65
• Elderly more likely to present w/
• dyspnea
(49%)• diaphoresis
(26%)
• nausea
and vomiting
(24%)
• syncope
(19%)
• Elderly more likely to present w/
• dyspnea
(49%)• diaphoresis
(26%)
• nausea
and vomiting
(24%)
• syncope
(19%)
Am J Cardiol. 1990;66:533–7.
– Atypical presentations portend worse prognosis
– 3‐fold higher risk of in‐hospital death 13% vs 4%
– Silent MI/Unrecognized MI
• 25% of all MIs
• up to 60% of MIs in pts >85 yr
– Delays in diagnosis and treatment
– Less use of evidence‐based medications
Elderly ECG
• Elderly pts more likely nondiagnostic ECGs
• Proportion of NSTE ACS pts with nondiagnostic
ECGs increased from 23% to 43% for those <65 vs >85 yrs
• Lack of CP on presentation
likely contributes to delays
• Delays in ACS recognition =
lower use of early
antithrombotic therapy for
ACS in elderly pts
• Cardiac cath: mean time
from arrival
• 34.4 hrs in pts <65 • 59 hrs for pts >85 yrs
• Lack of CP on presentation
likely contributes to delays
• Delays in ACS recognition =
lower use of early
antithrombotic therapy for
ACS in elderly pts
• Cardiac cath: mean time
from arrival • 34.4 hrs in pts <65 • 59 hrs for pts >85 yrs
J Am Coll Cardiol. 2005; 46: 1479–1487.
Should we give them a kick at the can…
should we send them for cath?
•Early coronary angiography •VS conservative strategy (OMT alone)
•primary outcome: composite of MI, urgent revascularisation, stroke, and death
•Early coronary angiography •VS conservative strategy (OMT alone)
•primary outcome: composite of MI, urgent revascularisation, stroke, and death
Lancet 2016 Mar 12;387(10023):1057‐65
• 47% Reduction in Primary Outcome!– Largely driven by reduction in MI and need for urgent
revascularization
• 47% Reduction in Primary Outcome!– Largely driven by reduction in MI and need for urgent
revascularization
What was the price to pay?
NO Difference in Major or Minor Bleeding!Invasive strategy is superior to a conservative
strategy
REASONS?
• ?healthier population
• Equal rates of antithrombotic use
• More radial approaches (~90%)
Case 2 – the frequent flyer, the frequent faller
• 85F recently discharged for failure to thrive, found
to have recurrent UTI
• Multiple comorbidities, polypharmacy
• History of Dementia
• History of AF on Warfarin• Labile INRs in the
community
• History of 3 mechanical falls in the last year
Would you consider
A.ASA alone
B.Warfarin
C.NOAC
D.Nothing
JAMA. 2001;285(18): 2370–5.
Prevalence of Atrial fibrillationPrevalence of Atrial fibrillation
CHALLENGES WITH ANTICOAGULATION IN ELDERLY PATIENTS WITH AF
Time in Therapeutic Range
Chest 2006;129(5):1155‐66.
Warfarin Interactions
Acetaminophen Carbamazepine Disulfiram Haloperidol
Allopurinol Cephalosporins ErythromycinInfluenza virus
vaccine
Anabolic steroids Cimetidine Fluconazole Metronidazole
Azathioprine Ciprofloxacin Fluorouracil (5‐FU) Macrolide antibiotics
Antithyroid drugs ClofibrateFluoxetine Nafcillin
Aspirin Clopidogrel Glucagon Omeprazole
AmiodaroneDicloxacillin
GlutethimideOral contraceptives
Capecitabine Diclofenac Griseofulvin Phenobarbital
Acetaminophen Carbamazepine Disulfiram Haloperidol
Allopurinol Cephalosporins ErythromycinInfluenza virus
vaccine
Anabolic steroids Cimetidine Fluconazole Metronidazole
Azathioprine Ciprofloxacin Fluorouracil (5‐FU) Macrolide antibiotics
Antithyroid drugs ClofibrateFluoxetine Nafcillin
Aspirin Clopidogrel Glucagon Omeprazole
AmiodaroneDicloxacillin
GlutethimideHormone
replacement
Capecitabine Diclofenac Griseofulvin Phenobarbital
Risk of Falls
• Risk of falls and ICH with warfarin often quoted as reason to avoid
anticoagulation
Multivariate analysis• N = 515
• High falls risk NOT significantly assoc with
risk of major bleed
• Risk of falls and ICH with warfarin often quoted as reason to avoid
anticoagulation
Multivariate analysis• N = 515
• High falls risk NOT significantly assoc with
risk of major bleed
Am J Med. 2012 Aug;125(8):773‐8.
Arch Intern Med. 1999;159:677–85.
AVERROES
What’s the downside?
Apixaban
(N=2808) Aspirin
(N=2791) HR with Apixaban
(95% CI) P Value
Major 1.4 1.2 1.13 (0.74–1.75) 0.57
ICH 0.4 0.4 0.85 (0.38–1.90) 0.69
GI 0.4 0.4 0.86 (0.40–1.86) 0.71
Non‐GI 0.6 0.4 1.55 (0.77–3.12) 0.22
Fatal 0.1 0.2 0.67 (0.19–2.37) 0.53
Minor 6.3 5.0 1.24 (1.00–1.53) 0.05
Apixaban
did NOT
increase the risk for major bleeding!
BAFTA
• N= 973 • >75 yrs (mean 81.5 yrs) with afib
– 20% of pts >85
• Randomly assigned to warfarin
(INR 2–3) or ASA
(75 mg)
• F/U mean of 2.7 yrs
• Primary endpoint: fatal or
disabling stroke, ICH, or clinically
significant arterial embolism
Lancet. 2007;370:493–503. Lancet. 2007;370:493–503.
Yearly risk Warfarin 1∙8% vs
3∙8%• RR 0∙48, 95%
CI 0∙28–0∙80,
p=0∙003
• Absolute yearly risk
reduction 2%
And the Risk risk of Hemorrhage…
Warfarin Aspirin p
Major
extracranial
hemorrhage
1.4% 1.6% 0.67
Other hospital
admission for
hemorrhage
1.8% 1.5% 0.52
All major
hemorrhages (ICH
and hemorrhagic
stroke)
1.9% 2.0% 0.9
Although overtreatment is a concern…
• Older adults may also be undertreated
because of potentially “ageist”
attitudes
• Belief
that chronological age =
contraindication to treatments
KEY POINT #1 – False Equivalence
INVASIVE MANAGEMENT for NSTEMI
ACUTE KIDNEY INJURY: 3%
invasive group vs 2% conservative management
REDUCTION in MYOCARDIAL INFARCTION or URGENT REVASC
70% of strokes result in
death or major disability
Most patients survive
major hemorrhage
without long‐term effects
Stroke 2013;44:99‐104.Stroke 2013;44:99‐104.
KEY POINT #2 Greater Benefit of the intervention
• Higher Event rate• Potential greater
response to treatment
• Number needed to treat in older patients lower
compared to younger
counterparts
MYOCARDIAL INFARCTION: Number Needed to Treat by Age and Risk
Efficacy (RRR)
Efficacy (RRR)
Num
ber N
eede
d to
Tre
at
Patient Age (Yrs)
REF: Alter DA, Manuel DG, Gunraj N, Anderson G, Naylor CD, Laupacis A. Age, Risk-Benefit Tradeoffs, and the Projected Effects of Evidence-based Therapies. Am J Med. 2004;116:540-5.
*Mortality Estimates based on AMI patients treated in Ontario from 1997-2000
How about the >75 with NOACs vs ASA?
Age Ageing. 2016 Jan;45(1):77‐83.
• Older pts with AF = particularly high risk of stroke if given ASA
• Substantially greater benefits from apixaban c/w younger pts with NO greater risk of
hemorrhage
Age NNT to prevent stroke or systemic embolization for apixaban vs ASA
<85 59
>85 15
Death from worsening Heart Failure
Systolic Heart Failure
Eur Heart J 2004; 25:1300
Hypertension Management – SPRINT TRIAL
TYPICAL CARDIAC Patient?
Geriatric Cardiology
Keeping in Mind, Major Geriatric Components
What the Future Holds
• Increased Research:– Inclusion of geriatric
patients– Increased research into
afib/HFPEF– “Non‐invasive”
Cardiac
Procedures –
Structural
heart program– Validated and agreed
upon FRAILTY TOOLS
• Increased cross‐ pollination between
the specialties– ACC/AHA geriatric
cardiology section– Increased partnership
with Canadian geriatric
society– TAVI (SPH/VGH)– High Risk Heart Failure
in the Elderly (MSJ)
In Summary
Summary Continued