Cardiac Intervention in the Elderly

1. Cardiac Intervention in the Elderly

2. Cardiac Interventions • Coronary Artery Bypass Grafting (CABG) • Percutaneous Transluminal Coronary Angioplasty (PTCA) ± stenting • Valve surgery • Radio-frequency Ablation • Automatic Implantable Cardiac Defibrillators (AICDs)

3. Ischaemic Heart Disease • Largest single cause of death in developed world • Medical therapy • CABG (Favaloro in 1969) • PTCA (Gruentzig in 1977) • Coronary stents (Sigwart in 1989)

4. CABG • 600 000/year in the USA Many trials selective/unrepresentative: • Males under 65 years old • Pre- Aspirin/Beta-blocker/ACE-I/Statin era • Saphenous vein grafts only

5. CABG - Mortality Mortality (in-hospital) 1.3% Predictors: • AGE • Co-morbidity • Pre-operative LV function • Surgical parameters • IABP requirement

6. CABG – MortalityNNECDSG SCORE • Age + Gender • LV Ejection Fraction • Urgency of Surgery • Previous CABG • PVD, Diabetes, Renal Failure, COAD • Body Habitus

7. NNECDSG score Each point = 0.2 – 2 % rise in mortality

8. CABG – 30 day Mortality

9. CVA 3% Prior neurological disease IABP use Diabetes Hypertension Unstable angina Increased age Prox. aortic atheroma Drop in intellect 3% Excess alcohol consumption Arrhythmias Hypertension Previous CABG Peripheral vascular disease Congestive heart failure Increased age CABG – Neurological risks

10. CABG – MorbidityRenal failure • 8 % of all patients • 1 % require dialysis (1.2 % of > 70 years) Major predictor of mortality • 18 % of patients die • 66% of dialysis patients die Risk factors • Advanced age, CCF, re-do surgery, diabetes

11. CABG – MorbidityMediastinitis • Deep sternal wound infection • 1% to 4% of patients • Mortality of 25% • Predicted by: • Obesity • Re-do surgery • Use of both IMA’s at surgery • Diabetes mellitus

12. Survival after CABGCABG vs. Medical Rx Mortality: @ 5 years: 10.2 % (CABG) vs. 15.8 % (medical) @ 10 years: 26.4 % (CABG) vs. 30.5 % (medical) Greatest benefit: • Left main stem or equivalent • Proximal LAD involvement

13. Survival after CABGProximal LAD disease • Relative risk reduction for CABG compared with medical treatment • 42 % @ 5 years • 22 % @ 10 years • Benefit increased if LV impaired

14. PTCA  stent • Most trials performed before: • Stents • Clopidogrel • IIb/IIIa platelet inhibitors • 447 000 procedures/year in USA (1997)

15. PTCA  stent • Procedural success now 99.5% (76% in 1986) • Mortality • 0.91% (UK values) • 0 % (stents) • 1.2% (stents in diabetic patients) • Early repeat procedure (<7 months after 1st) • 23.3 % with POBA • 13.5 % with stents

16. PTCA (no stent)Mortality/morbidity 10 year follow-up: • Q-wave MI 3.9% • non Q-wave MI 11.3% • Death 23.1 % • CABG 32.7 % • Repeat procedure 38% • Recurrent angina 56.3 % • Risk factors: • Extent of disease • Diabetes • Hypertension • Previous MI • Male • Age >70 (mortality)

17. PTCA + stentingMortality/morbidity Follow – up data is over shorter period Most data is pre - ticlopidine/clopidogrel • Death rate @ 1 year 0.7 – 1.2% • Target lesion re-intervention 15% (1yr) • Cardiac event free survival 78% (1yr) Outcomes similar for single vs. multivessel

18. PTCA + stentingMortality/morbidity Influence of ticlopidine • MACE level dropped from: • 24.1% to 9.0 % (in hospital) • 47% to 33% (2 years)

19. PTCA  stentingInfluence of age Study from 1980 –1996

20. PTCA  stentingInfluence of age

21. CABG or PTCA? • Data pre-stent / clopidogrel / IIb/IIIa inhibitors • BARI trial:Lower mortality with CABG vs. PTCA • Diabetic patients do better with CABG • Non-diabetic patients – No difference • QALY/activity/employment/costs equivalent at 5 years • Recurrence of angina higher in PTCA • 21% vs 15% @ 5 years

22. Age > 80 years MVR AVR Valve surgery in > 80 yrs age • High rate of co-morbidity • 40-60% IHD  15-25% COAD • 5-25% CVA 20-50% Hypertension

23. Age > 80 years MVR AVR Valve surgery in > 80 yrs age Risk score EF: 30-50% +2 EF <30% +5 Re-operation +2 Valve & CABG +2

24. Valve surgery in > 80 yrs ageAppropriateness of surgery • AVR for severe aortic stenosis +++ • MVR for severe mitral regurgitation ++ • AVR for moderate AS during CABG ++ • MV repair for moderate MR at CABG + • Balloon valvuloplasty for MS + • MVR for moderate MR during CABG 0 • AVR + MVR 0 • Balloon valvuloplasty of aortic valve 0

25. Symtomatic Aortic Stenosis in the > 80 Year Old

26. Radio-frequency ablation • Introduced in the 1980’s • Treatment of choice in symptomatic SVT’s • AVNRT • AVRT (i.e. WPW) • Atrial flutter • NO PROGNOSTIC ADVANTAGE

27. RFA Statistics • Mortality 0.3% • Major complication 3% • Success 85 – 100% (95%) • Recurrence 2 – 21%

28. RFA in the elderly • Little data • Most common procedure is AVJ (node) ablation for atrial fibrillation + PPM • Age not a predictor of success/complication • Structural heart disease • Multiple accessory pathways • Heart disease • Low ejection fraction • AVJ ablation Complications Death

29. AICD’s • Undoubted prognostic benefit • Procedural mortality 0.5 – 0.8 % • Primary prevention • Secondary prevention

30. AICD’s –Primary Prevention • Previous MI and all of the following: • Non-sustained VT on Holter (24 hour ECG) • Inducible VT at EPS • LV dysfunction • EF < 35% • NYHA I – III • Familial cardiac condition with risk of sudden death (long QT, HOCM etc.)

31. AICD’s – secondary prevention • Patients who present, in the absence of a treatable cause, with: • Cardiac arrest due to VT or VF • Sustained VT causing syncope or significant haemodynamic compromise • Sustained VT without haemodynamic compromise + EF < 35% + NYHA I - III

32. Conclusions • Age is a significant risk factor in most cardiac interventions, but does not preclude intervention • Co-morbidity is a major factor in deciding appropriateness of intervention • AVR is well worthwhile in isolated AS • Treat the person, not the birth date!