preventive care for the older adult
TRANSCRIPT
Preventive Care for the Older Adult
Dr. Don Geiger Keynote AddressDov Gandell MDCM, FRCPC
Staff physician, Sunnybrook Health Sciences CentreAssistant professor, University of Toronto
May 1, 2019
Conflict of Interest
• None to declare
• “There is only one ultimate and effectual preventative for the maladies to which flesh is heir, and that is death.”
• Harvey Cushing 1869 - 1939
• “An ounce of prevention is worth a pound of cure.”
• Benjamin Franklin 1706 - 1790
Objectives
• Identify and review recently published trials that test interventions to prevent cardiovascular disease in older adults
• Identify an upcoming trial that will further inform prevention in the care of older adults
• Consider another important outcome in cardiovascular prevention trials
300 BCBark from willow tree recognized for healing
properties - salicin
1853 – 1897Acetylsalicyclic acid
synthesized
2002ATT
Event and mortality benefit ASA in
secondary prevention
2009ATT
ASA primary prevention 20% RRR
myocardial infarct
2016US Preventive
Services Task Force
2018ARRIVE, ASCEND,
ASPREE
1988ISIS – 2
ASA mortality benefit in acute myocardial
infarction
N Engl J Med 2018; 379:1499-1508
N Engl J Med 2018; 379:1509-1518
N Engl J Med 2018; 379:1519-1528
• Multicenter, randomized, double-blind, placebo-controlled trial
• N = 19 114
• 4.7 years
• Intervention• Enteric-coated aspirin 100mg daily versus placebo
• Primary outcome• Composite death, dementia, or persistent physical disability• Cardiovascular events and bleeding• All-cause mortality
N Engl J Med 2018; 379:1499-1528
• Inclusion• ≥ 70 years old
• Community dwelling
• Free from documented cardiovascular or cerebrovascular disease
• Life expectancy greater than 5 years
• Average participant• Moderate to high – Framingham risk
• 50% ≥ 74 years old
• 56% female
• 85% Australian
• 74% hypertension, 64% cholesterol, 10% diabetic
• 10% prior ASA use
N Engl J Med 2018; 379:1499-1528
• Disability-Free Survival• HR 1.01 (95 CI 0.92 – 1.11, p = 0.79)
• 21.5 vs 21.2 events / 1000 person-years
N Engl J Med 2018; 379:1499-1508
• Cardiovascular events• HR 0.95 (95 CI 0.83 – 1.08)
• 10.7 vs 11.3 events / 1000 person-years
N Engl J Med 2018; 379:1509-1518
• Major hemorrhage• HR 1.38 (95 CI 1.18 – 1.62, P < 0.001)
• 3.8% versus 2.8%
N Engl J Med 2018; 379:1509-1518
• All-cause mortality
• HR 1.14 (95 CI 1.01 – 1.29)
• 12.7 vs 11.1 events / 1000 person-years
N Engl J Med 2018; 379:1519-1528
Any Cancer295 vs 227 HR 1.31 (1.10 – 1.56)
GI including colorectal35 vs 20 HR 1.77 (1.02 – 1.36)
•ASCEND• Multicenter, randomized, double-blind, placebo-controlled trial
• Men/women, 40 years and older, diabetes
• N = 15 480, 7.4 years
• Aspirin 100mg daily versus placebo
• Serious vascular events• 8.5% versus 9.6% RR 0.88 CI 0.79 – 0.97, p=0.01
• Older adult subgroup ≥ 75 years old - NS
• Major bleeding• 4.1% versus 3.2% RR 1.29 CI 1.09 – 1.52, p = 0.003• No difference all cause mortality• No difference incident cancer
N Engl J Med 2018; 379:1529 - 1539
•ARRIVE• Multicenter, randomized, double-blind, placebo-controlled trial
• Men/women, 64 years, not diabetic, Framingham 14%
• N = 12 546, 5 years
• Aspirin 100mg daily versus placebo
• Serious vascular events• 4.29% versus 4.48%, HR 0.96, CI 0.81 – 1.13, p = 0.60
• Major bleeding• 0.97% versus 0.46%, HR 2.22, CI 1.36 – 3.28, p = 0.0007• No difference all cause mortality• Cancer incidence not reported
Lancet 2018;392:1036-1046
•ASPREE, ASCEND, ARRIVE• Primary prevention risk based on age
• Hypertension and lipid control
• Secondary prevention risk based on extent of cardiovascular disease
• Cancer• ASCEND, longer follow-up, did not reveal increased incidence or death
from cancer
• ARRIVE yet to report on cancer incidence
• Secondary finding in ASPREE
• ASPREE Cancer Endpoint Study (ACES)
N Engl J Med 2018; 379:1499-1528
Bottom Line
STOP ASA for primary prevention in older adults
ASA – less is moreBlood pressure control – more is less
JAMA 2016;315(24):2673-2683
• Multicenter, randomized controlled trial• Subgroup analysis
• N = 2636
• Intervention• Systolic blood pressure (SBP) < 120mmHg (intensive) versus SBP target <
140mmHg (standard)
• 3 years
• Primary outcomes• MACE (nonfatal myocardial infarct, acute coronary syndrome, nonfatal stroke,
nonfatal congestive heart failure, death from cardiovascular causes)
JAMA 2016;315(24):2673-2683
• Inclusion• Age ≥ 75
• Exclusion• Diabetes
• Stroke
• Symptomatic heart failure, EF < 35%
• Standing systolic blood pressure less than 110mmHg
• Dementia, residing in a nursing home
JAMA 2016;315(24):2673-2683
• Average participant• 79.9 years old
• Female (38%), white (74%)
• MoCA score 22
• GFR < 60 mL/min (44%)
• Frailty index (36 item) 0.18• Fit ≤ 0.1 (13%)
• Less fit 0.1 < FI ≤ 0.21 (55%)
• Frail > 0.21 (32%)
• Gait speed 0.9m/s (median), < 0.8m/s (28%)
• Groups balanced
JAMA 2016;315(24):2673-2683, J Gerontol A Biol Sci Med Sci. 2016 May; 71(5): 649–655
•Results• Blood pressure achieved
• 123/62mmHg intensive versus 134/67mmHg standard
• Primary composite outcome HR 0.66 (95 CI 0.51 – 0.81)
• 102 vs 148 events, NNT 27
• Secondary all-cause mortality HR 0.67 (95 CI 0.49 – 0.91)
• 73 vs 107 events, NNT 41
JAMA 2016;315(24):2673-2683
JAMA 2016;315(24):2673-2683
• Adverse events • No difference in serious adverse events (SAEs)
• Orthostatic hypotension 21% vs 21%
• Hypotension 2.4% vs 1.4%
• Syncope 3.0% vs 2.4%
• Electrolyte abnormality 4.0% vs 2.7%
• Acute kidney injury 5.5% vs 4.9%
JAMA 2016;315(24):2673-2683
Bottom Line
Subgroup analysis results hard to ignore
Very careful patient selection, patient-centered, not frail
A Clinical Trial of STAtin Therapy for ReducingEvents in the Elderly (STAREE)• PROSPER 2002
• CCS guidelines limited to ≤ 75 years old
• ≥ 70 years old, independent community dwelling
• Atorvastatin 40mg daily versus placebo
• N = 18 000, 2015 - 2022
• Primary Outcome• Death or dementia or disability
• Major fatal or non fatal cardiovascular event
ClinicalTrials.gov Identifier: NCT02099123
JAMA. 2019;321(6):553-561. doi:10.1001/jama.2018.21442
• Multicenter, randomized, double-blind, placebo-controlled trial
• N = 8626
• 3.34 years median treatment period, 5 year median follow-up
• Intervention• Systolic blood pressure (SBP) < 120mmHg (intensive) versus SBP target < 140mmHg
(standard)
• Primary outcome• Probable dementia (blinded adjudicators – cognitive test scores, function score)• Mild cognitive impairment (MCI)• Probable dementia or MCI
JAMA. 2019;321(6):553-561. doi:10.1001/jama.2018.21442
• Inclusion• Clinical or subclinical cardiovascular disease
• Chronic kidney disease (EGF 20 – 59mL/min, < 1g/d proteinuria)
• Age ≥ 75
• Estimated 10 year global cardiovascular risk ≥ 15%
• Exclusion• Diabetes
• Stroke
• Symptomatic heart failure, EF < 35%
• Standing systolic blood pressure less than 110mmHg
• Dementia, residing in a nursing home
JAMA. 2019;321(6):553-561. doi:10.1001/jama.2018.21442
• Average participant• 67.9 years old, 30% greater than 75 years
• 65% male
• 58% Caucasian
• BP 139/78 mm Hg
• 20% history of cardiovascular disease
• MoCA 23/30
JAMA. 2019;321(6):553-561. doi:10.1001/jama.2018.21442
Probable dementia 7.2 vs 8.6 /1000 person years (HR 0.83, CI 0.67 – 1.04), p = 0.10
•Results• MCI 14.6 vs 18.3 p = 0.007• MCI or dementia 20.2 vs 24.1 p = 0.01• Older adult subgroup (>75) HR 0.88 p = 0.84
• Discussion• Incident dementia
• Attrition• Early termination• Young participants, length of follow-up
• Blood pressure targets did not confer harm• Secondary outcome, possible benefit
• MCI risk factor for dementia• Changes in specific cognitive domains not reported
JAMA. 2019;321(6):553-561. doi:10.1001/jama.2018.21442
Bottom Line
Intensive systolic blood pressure control does not prevent dementia syndrome
SPRINT MIND 2.0 – further 2 year follow-up
Cognitive pause
• Harriette Thompson
• 92 years, 65 days
• 2015 Rock n’ Roll San Diego Marathon
• 7:24:36
• No data on her primary prevention strategies
Canadian Cardiovascular Society
• Adults should accumulate at least 150 minutes of moderate to vigorous-intensity aerobic physical activity per week, in bouts of 10 minutes or more to reduce CVD risk• Strong Recommendation; High-Quality Evidence
• How well to these guidelines extend to older adults?
Can J Cariol 2016;32;11;1263-1282
J Am Geriatr Soc 66:886–894, 2018.
• Prospective cohort study• Objective Physical Activity and Cardiovascular Health – OPACH• Women’s Health Initiative
• N = 7048
• 3.1 years
• Intervention• Hip-worn triaxial accelerometer
• Primary outcome• All-cause mortality
J Am Geriatr Soc 66:886–894, 2018.
• Average participant• 78.6 years old
• 50% white
• BMI 28.1 Kg/m2
• 1.6 comorbid conditions
• 334 minutes/day total physical activity• Low light physical activity 56.1%
• Wash/dry dishes (1.6 – 2.2 METs)
• High light intensity physical activity 29%• Slow walking 2.4km/hr (2.3 – 2.9 METs)
• Moderate to vigorous physical activity 14.9%• Brisk walking (≥3 METs)
J Am Geriatr Soc 66:886–894, 2018.
•Results• Moderate to vigorous physical activity RR 0.67 (CI 0.58 – 0.78)
• Light physical activity RR 0.93 (CI 0.89 – 0.97)
• 30 minute increments of light physical activity per day• relative risk reduction of death of 12%, p < 0.01
• Discussion• Accuracy of data by objective measurement rather than
questionnaire• Precision – dose response
J Am Geriatr Soc 66:886–894, 2018.
Bottom Line
There is evidence to support below guideline physical activity recommendations for older women
www.exerciseismedicine.org
CMAJ 2012;184(18):1985-1992
• Prospective cohort design• Whitehall II study 1991 - 1994
• N = 5100• 42 – 63 years old (free of cancer, coronary disease, stroke)
• 16.3 years follow-up
• Intervention• 4 healthy behaviours
• never smoking
• moderate alcohol
• physical activity
• daily intake fruits and vegetables
• Primary outcome• Good cognitive, physical, respiratory, and cardiovascular function
• Absence disability, mental health, chronic disease
CMAJ 2012;184(18):1985-1992
CMAJ 2012;184(18):1985-1992
Bottom Line
Primary cardiovascular prevention for older adults starts well before ‘older’ applies
Summary
• ASA is not effective in preventing primary cardiovascular events in older adults
• Intensive systolic pressure targets do not appear to prevent dementia in the short term but did not have negative effects on cognition
• Data exist for below guideline dose/intensity physical activity in older adults with healthy behaviors conferring additive preventive effects
