cardiac intervention in the elderly
Download
Skip this Video
Download Presentation
Cardiac Intervention in the Elderly

Loading in 2 Seconds...

play fullscreen
1 / 32

Cardiac Intervention in the Elderly - PowerPoint PPT Presentation


  • 137 Views
  • Uploaded on

Cardiac Intervention in the Elderly. Cardiac Interventions. Coronary Artery Bypass Grafting (CABG) Percutaneous Transluminal Coronary Angioplasty (PTCA) ± stenting Valve surgery Radio-frequency Ablation Automatic Implantable Cardiac Defibrillators (AICDs). Ischaemic Heart Disease.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Cardiac Intervention in the Elderly' - aric


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
cardiac interventions
Cardiac Interventions
  • Coronary Artery Bypass Grafting (CABG)
  • Percutaneous Transluminal Coronary Angioplasty (PTCA) ± stenting
  • Valve surgery
  • Radio-frequency Ablation
  • Automatic Implantable Cardiac Defibrillators (AICDs)
ischaemic heart disease
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)
slide4
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
cabg mortality
CABG - Mortality

Mortality (in-hospital) 1.3%

Predictors:

  • AGE
  • Co-morbidity
  • Pre-operative LV function
  • Surgical parameters
  • IABP requirement
cabg mortality nnecdsg score
CABG – MortalityNNECDSG SCORE
  • Age + Gender
  • LV Ejection Fraction
  • Urgency of Surgery
  • Previous CABG
  • PVD, Diabetes, Renal Failure, COAD
  • Body Habitus
nnecdsg score
NNECDSG score

Each point = 0.2 – 2 % rise in mortality

cabg neurological risks
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
cabg morbidity renal failure
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
cabg morbidity mediastinitis
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
survival after cabg cabg vs medical rx
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
survival after cabg proximal lad disease
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
ptca stent
PTCA  stent
  • Most trials performed before:
      • Stents
      • Clopidogrel
      • IIb/IIIa platelet inhibitors
  • 447 000 procedures/year in USA (1997)
ptca stent15
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
ptca no stent mortality morbidity
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)
ptca stenting mortality morbidity
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

ptca stenting mortality morbidity18
PTCA + stentingMortality/morbidity

Influence of ticlopidine

  • MACE level dropped from:
    • 24.1% to 9.0 % (in hospital)
    • 47% to 33% (2 years)
ptca stenting influence of age
PTCA  stentingInfluence of age

Study from 1980 –1996

cabg or ptca
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
valve surgery in 80 yrs age
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
valve surgery in 80 yrs age23
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

valve surgery in 80 yrs age appropriateness of surgery
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
radio frequency ablation
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
rfa statistics
RFA Statistics
  • Mortality 0.3%
  • Major complication 3%
  • Success 85 – 100% (95%)
  • Recurrence 2 – 21%
rfa in the elderly
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

aicd s
AICD’s
  • Undoubted prognostic benefit
  • Procedural mortality 0.5 – 0.8 %
  • Primary prevention
  • Secondary prevention
aicd s primary prevention
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.)
aicd s secondary prevention
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
conclusions
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!
ad