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Umberto Baldini Cardiologia - Livorno

Peculiarità del paziente anziano cardiopatico. Umberto Baldini Cardiologia - Livorno. Congresso regionale ANMCO Viareggio, 7-8 ottobre 2011. “…….sistematically developed statements to assist practitioner and patient decisions about appropriate

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Umberto Baldini Cardiologia - Livorno

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  1. Peculiarità del paziente anziano cardiopatico Umberto Baldini Cardiologia - Livorno Congresso regionale ANMCO Viareggio, 7-8 ottobre 2011

  2. “…….sistematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances……” Field MJ,Lohr KN (eds). Guidelines for Clinical Practice: from development to use. 1992,Institution of Medicine, National Academy Press, Washington, DC.

  3. Guidelines diffusion

  4. Numero e gravità delle patologie croniche in base al sesso e all’età ISTAT 2004-2005

  5. Consumo quotidiano medio di farmaci per età e sesso (USA) Kaufman DW et al. JAMA 2002

  6. Peculiarità Comorbilità Politerapia Età > 75 aa. -Incontinenza -Cadute -Problemi nutrizionali -Osteoporosi -Anemia Cognitivo Fisico Psichico Socio- economico Declino funzionale

  7. Peculiarità

  8. Paziente anziano, fragile RISCHIO di “ROTTURA” Noxae patogene (ACS) Interventi terapeutici (danni jatrogeni)

  9. Orientate su una specifica patologia RCT altamente selezionati (non contemplano pazienti complessi e “fragili”) Non contemplano l’eterogeneità del paziente geriatrico (comorbilità, politerapia, stato funzionale e cognitivo, stato socio-familiare) Tinetti M et al. NEJM 2004; 351:2870-4

  10. ACS Trials and Registries: Characteristics and Outcome * Cr >2 mg/dl , Cr clearance<30 mL/min, orneed for dialysis ^ in-hosp death

  11. BLITZ 2: invasive treatment Invasive approach % 21 > 75 years < 75 years

  12. BLITZ : STEMI in patientsolderthan 75 years n. 296 34,1 8,8 PPCI Lysis No rep. De Luca L et al. J CardiovascMed 2008, 9:1045–1051

  13. GRACE (0-258) RiskScores in ACS TIMI (0-7) Class I-B LG ESC PURSUIT (0-18)

  14. Creatinine 1,2 mg/dl 30-yr, 110 kg 77-yr,  55 kg Cl CR 110 ml/min Cl CR 30 ml/min

  15. 1-year Mortality Charlson Comorbidity Index Charlson ME et al. J ChronDis 1987;40:373

  16. Impact of associated comorbidities on management in elderly ACS Charlson Index No inv. Inv. Passamontiet al. ItalHeart J Suppl 2004; 5 (11); 855-860

  17. 1-year Mortality Risk after Hospitalization in Elderly PtsMeasures of functional status add important information ADL activities of daily living (eating, bathing, using the toilet, dressing, moving from bed to chair) Walter L et al. JAMA 2001;285:2987 Lee S et al. JAMA 2006;295:801

  18. TACTICS-TIMI 18: Clinicaloutcomesstratifiedbyage (Invasive vs Conservative strategy) Death or non-fatal MI Death, MI or rehospitalization P=0.016 P=0.05 Invasive strategy Better Conservative strategy Better Invasive strategy Better Conservative strategy Better Bach RG et al. AnnInternMed 2004; 141: 186-95

  19. CKD: an independent and graded Risk Factor of Death, CV events and HospitalizationKaiser Registry 1.120.295 patients / 2.8 years Go A et al. N Engl J Med 2004;351:1296-305

  20. ACS Registries: ACS I-II e GRACE 11742 paz 1999-2007 Canada

  21. ACS I-II e GRACE: mortalità in base a strategia terapeutica (conservativa vs invasiva) 1-year mortality % p <0.043 p <0.001 p <0.001 <30 30–59 >60eGFR in mL/min/1.73m2 Jannuzzietal. Am J Cardiol 2002;90:1246 Wong JA et al Eur Heart J 2009; 30: 549-57

  22. Primary • Relevant rise or fall in troponina • Dynamic ST- or T-wave changes (symptomatic or silent) Secondary • Diabetesmellitus • Renalinsufficiency (eGFR <60 mL/min/1.73 m²) • Reduced LV function (ejection fraction <40%) • Early post infarction angina • Recent PCI • Prior CABG • Intermediate to high GRACE risk score (Table 5) Criteria for high risk with indication forinvasive management 2011 ESC Guidelines on NSTE ACS

  23. Effects of Renal Insufficiency on In-hosp major bleedings (TACTICS-TIMI 18 e ACS I-II, GRACE) In-hosp major bleedings, % ACS I ACS II GRACE <30 31–60 61–75 >75 Creatinine Clearance (ml/min) Jannuzzi et al. Am J Cardiol 2002; 90: 1246 Wong JA et al. Eur Heart J 2009; 30: 549-57

  24. Death Adj HR(95% CI) 2.9% 3.5% 1.6 (1.3-1.9) 5.9% 2.7 (2.3-3.4) 25.7% 10.6 (8.3-13.6) Bleeding portends increased 30-Day mortality in NSTE ACS26,452 GUSTO IIb, PURSUIT and PARAGON A & B pts Raoet al. Am J Cardiol 2005;96:1200

  25. Assessment of bleeding risk • An important component of the decision making process (Class I, Evidence C) • Bleeding risk increased with: • excessive dosage of anti-thrombotic agents • switch between different anticoagulants • reduced renal function • older age • low body weight • female gender 2011 ESC Guidelines on NSTE ACS

  26. Take home messages Treatment decisions in the elderly (>75 years) shouldbe made in the context of estimated life expectancy, co-morbidities, qualityoflife, and patient wishes and preferences Reduce the number of medications an older patient is taking in a systematic way, with a focus on maintaining functional status and quality of life, by weighing the use of each medication against potential side effects and interactions

  27. Take home messages Elderlypatientsshouldbeconsideredforanearly invasive strategywith the optionofpossiblerevascularization, aftercarefulweighing up of the risks and benefits Choice and dosageofantithromboticdrugsshouldbe tailored in elderly patients to prevent the occurrence of adverseeffects

  28. ARMOR: A Tool to Evaluate Polypharmacy in Geriatric Patients Haque R. Ann Longterm Care. 2009:26-30.

  29. Naturalhistoryofaorticstenosis 476 patients 75-86 years 412 no AS (2.1 cm2) 25 mild AS (1.2 cm2) 26 moderate (0.9 cm2) 13 severe AS (0.6 cm2) 4-year follow-up Iivanainen et al. Am J Cardiol 1996

  30. Survival of asymptomatic patients with severe aortic stenosis versus age-matched US population Pellikka PA, Circulation 2005; 111: 3290–95

  31. Survivalofpatientswithaorticstenosisovertime

  32. Meansurvivalofpatientswithsymptomsof AS Schwarz F,. Circulation 1982; 66: 1105–10.

  33. Transcatheter aortic valve implantation: A systematic review of current literature. • Success rate 93.3%. • Cumulative mortality (procedural, post-procedural, and in-hospital/30-day) 11.4% (n = 116) • 1 year survival rate 75.9% vs 62.4% (med treated) (p< 0.01). • 1-year survival for TV higher than TA procedures (79.2 vs. 73.6%) (p = 0.04). • At 1-year follow-up, the improved valvular function remained stable, and there was a trend towards an improved ventricular function. Figulla L et al. Clin Res Cardiol 2011 Apr;100(4):265-76.

  34. NSTEMI in elderly patients • Becauseof the frequentatypicalpresentation, elderlypatients (>75 years) should beinvestigatedfor NSTE-ACS at low levelofsuspicion (Class I, Evidence C) • Treatment decisions in the elderly (>75 years) shouldbe made in the context of estimated life expectancy, co-morbidities, qualityoflife, and patient wishes and preferences(Class I, Evidence C) • Choice and dosageofantithromboticdrugsshouldbe tailored in elderly patients to prevent the occurrence of adverseeffects(Class I, Evidence C) • Elderlypatientsshouldbeconsideredforanearly invasive strategywith the optionofpossiblerevascularization, aftercarefulweighing up of the risks and benefits(Class IIa, Evidence B) 2011 ESC Guidelines on NSTE ACS

  35. Drug Recommendations for Antithrombotic Drugs in CKD Aspirin No specific recommendations Bivalirudin Consider reduction of infusion rate to 1.0 mg/kg/h in severe renal dysfunctionConsider use of NSTE-ACS + reduced renal function (GFR 30-60 mL/min/1.73 m2) undergoing angiography ± PCI due to lower bleeding risk vs UFH + GP IIb/IIIa Clopidogrel No information in patients with renal dysfunction Enoxaparin/low-molecular-weight heparin In severe renal failure (GFR < 30 mL/min/1.73m2) avoid or use 50% dose and control of therapeutic levels by factor Xa-activity measurements. In reduced GFR (30-60 mL/min/1.73m2) use 75% dose Prasugrel No dosage adjustment is necessary for patients with renal impairment including patients with end-stage renal disease Ticagrelor No dose reduction required in patients with GFR < 60 mL/min/1.73m2 Unfractionated heparin Dose reduction based on frequent aPTT measurements to control therapeutic rangeGP IIb/IIIa antagonists Abciximab No specific recommendations Eptifibatide Dose adaptation in patients with moderate renal impairment (GFR < 60 mL/min/1.73m2) Contraindicated in severe renal dysfunction Tirofiban Dose adaptation required in patients with renal failure 50% dose if GFR < 30 mL/min/1.73m2

  36. http://www.crusadebleedingscore.org

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