Bill Weintraub : NCDR Founding Father
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Transcript of Bill Weintraub : NCDR Founding Father
Bill Weintraub : NCDR Founding Father
“Science tells us what we can do;
Guidelines what we should do;
Registries what we are actually doing.”
NCDR Temporal Experience
Exclusion of >75 Yrs from Cardiac RCTsReview of 593 UA/MI Trials
Exclusion of >75 Yrs from Cardiac RCTsReview of 593 UA/MI Trials
0
1020
3040
50
6070
8090
100
1966-70 1971-80 1981-90 1991-95 1996-00
Explicit Exclusion>75 No Pt >75 enrolled
Lee, JAMA 2001
Tri
als
No
t In
clu
din
g E
lder
ly (
%)
Tri
als
No
t In
clu
din
g E
lder
ly (
%)
NSTE ACS in ElderlyIn-Hospital Events
NSTE ACS in ElderlyIn-Hospital Events
2.8
67.4
8.5
13.3
16.1
02468
1012141618
Death Death/MI CHF
<75 Years >75 Years
* Kulkarni S et al ACC 2003 CRUSADE Presentation
Therapeutics in ACS Among Patients >90 Years Old
Therapeutics in ACS Among Patients >90 Years Old
In-hospital Mortality by Number of Therapies
0
5
10
15
20
25
30
None One Two Three Four Five
Number of Recommended Therapies* (p<0.001 for trend)
% m
ort
alit
y
Age 75-89
Age 90 and older
Major Bleeding by Number of Therapies
0
2
4
6
8
10
12
14
16
18
20
None One Two Three Four FiveNumber of Recommended Therapies*
(p<0.01 for trend) (CABG Pts and contraindications excluded)
% m
ajo
r b
leed
ing
**
Age 75-89
Age 90 and older
MortalityMortality Major BleedingMajor Bleeding
Even among oldest old – better outcomes with better adherence to ACC/AHA Guidelines
Even among oldest old – better outcomes with better adherence to ACC/AHA Guidelines
OptimalOptimal
- Skolnick et al, ACC 2006- Skolnick et al, ACC 2006
Inherent or Induced Problem?Excessive Antithrombotic Dosing by Age
Inherent or Induced Problem?Excessive Antithrombotic Dosing by Age
12.5
28.7
8.512.8
3733.1
16.5
38.5
64.5
0
10
20
30
40
50
60
70
LMW Heparin UF Heparin GP IIb/IIIa
% E
xcessiv
e D
ose
< 65 yrs 65-75 yrs >75 yrs
12.5
28.7
8.512.8
3733.1
16.5
38.5
64.5
0
10
20
30
40
50
60
70
LMW Heparin UF Heparin GP IIb/IIIa
% E
xcessiv
e D
ose
< 65 yrs 65-75 yrs >75 yrs
Alexander KA, JAMA 2005Alexander KA, JAMA 2005
0102030405060708090
100
<65 65-74 75-84 >85
BMI (kg/m2)CrCl (ml/min)Renal Insuff (%)
23,694 13,033 13,835 6,401N=
Patient Age
Renal Insuff defined as Serum Creat >2.0mg/dl
AHA Consensus Group on Management of ACS in the Elderly
AHA Consensus Group on Management of ACS in the Elderly
Renal Function and Age NonSTEMI ACS (GRACE)
0
10
20
30
40
50
60
Cath Stress Test Revasc
% A
MI P
atie
nts
65-69 70-74 75-79 >80 Alexander 2001 AHJAlexander 2001 AHJ
Post-MI Testing by Age CategoryMedicare
Post-MI Testing by Age CategoryMedicare
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
40 50 60 70 80 90
Age (years)
Pe
rce
nta
ge
Us
e
Cath
PCI
CABG
Invasive Procedure Use by Age
Alexander KA, JACC 2005;46:1479-87. Alexander KA, JACC 2005;46:1479-87.
Predictors of Early Cath in CRUSADEPredictors of Early Cath in CRUSADE
Adjusted Odds RatioAdjusted Odds Ratio
110.50.5 1.51.5 22
Cardiology CareCardiology Care
Age (per 10 yrs)Age (per 10 yrs)
Prior CHFPrior CHF
Renal InsufficiencyRenal Insufficiency
Signs of CHFSigns of CHF
Caucasian RaceCaucasian Race
Female SexFemale Sex
Bhatt et al, JAMA 2004Bhatt et al, JAMA 2004
In-Hospital Mortality by Age and Guidelines Adherence: Observations from CRUSADEIn-Hospital Mortality by Age and Guidelines Adherence: Observations from CRUSADE
3.13.5
5.26.7
8.7
10.4
17.6
0.61
1.82.7
3.5
10.7
6.5
0
2
4
6
8
10
12
14
16
18
20
0 1 2 3 4 5 6Number of Recommended Therapies
Pe
rce
nt
In-h
os
pit
al M
ort
ality
Age >=75 Age <75
- Boden et al, AHA 2005- Boden et al, AHA 2005
Adj. OR:Adj. OR: 0.71 (0.67-0.75)0.71 (0.67-0.75)0.79 (0.75-0.79 (0.75-0.83)0.83)
Age GroupAge Group
The Oldest Old (>90 years) with ACS: Observations From CRUSADE CQI
The Oldest Old (>90 years) with ACS: Observations From CRUSADE CQI
CRUSADE PopulationN: 142,335
CRUSADE PopulationN: 142,335
The Elderly (age >75)N: 46,270 – 33%
The Elderly (age >75)N: 46,270 – 33%
Oldest Old (age >90)N: 5,557 – 4%
Oldest Old (age >90)N: 5,557 – 4%
Death MI Bleeding
7.8% 3.5% 13.1%
12.0% 3.0% 9.9%
Death MI Bleeding
7.8% 3.5% 13.1%
12.0% 3.0% 9.9%
- Skolnick et al, ACC 2006- Skolnick et al, ACC 2006
Reason for No Cath Contraindication Among 9,884 High-Risk ACS PatientsReason for No Cath Contraindication Among 9,884 High-Risk ACS Patients
ReasonReason % of Pts% of Pts AgeAge
MedianMedian
Renal Renal FailureFailure
MortalityMortality
In-HospitalIn-Hospital
Pts RefusalPts Refusal 18%18% 8282 26%26% 4.2%4.2%
DNRDNR 16%16% 8585 29%29% 24.6%24.6%
Advanced AgeAdvanced Age 11%11% 9090 22%22% 5.1%5.1%
Active Active BleedingBleeding
4%4% 7777 30%30% 10.4%10.4%
Not Revasc PtNot Revasc Pt 17%17% 7878 35%35% 6.2%6.2%
Co-morbiditiesCo-morbidities 20%20% 7777 42%42% 15.5%15.5%
OtherOther 14%14% 7070 21%21% 5.7%5.7%
Secondary Prevention: It Works at all Ages!
Secondary Prevention: It Works at all Ages!
• Similar benefits of aspirin/beta-blockers: Similar benefits of aspirin/beta-blockers: CCPCCP
• Similar benefits of ace-inhibitors: Similar benefits of ace-inhibitors: HOPEHOPE
• Similar benefits of lipid lowering: Similar benefits of lipid lowering: HPSHPS
• Similar improvements in functional outcomes Similar improvements in functional outcomes with Cardiac Rehab: with Cardiac Rehab: Pasquali 2002 ACCPasquali 2002 ACC
Less Prevention Management Among Elderly Less Prevention Management Among Elderly Out-Patients in REACHOut-Patients in REACH
0102030405060708090
100
% o
f p
ati
en
ts i
n c
ate
go
ry
<65 65-75 76-85 >85
Age categories
≥1 anti-diabetic
≥1 antihypertensive
Use of a statin
≥1 antiplatelet
- Hirsch et al, ACC 2006- Hirsch et al, ACC 2006
Registry/QI• 1100 hospitals• >9 million patient
records• Online data entry tool• Support D2B Alliance
Research and Publications• DCRI analytic center• Over 100 publications
190272
321 362
472547
658
825
1000
0
100
200
300
400
500
600
700
800
900
1000
Fac
ilitie
s
1999 2000 2001 2002 2003 2004 2005 2006 2007F
CathPCI Registry Enrollment
Participants
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Age
<40 40-59 60-79 80
In-Hospital PCI Mortality = 1.22%In-Hospital PCI Mortality = 1.22%
Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26
NCDR : Age and PCI Mortality 2001-2006
n=25,679 n=496,204 n=732,574 n=155,612
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0M
ort
ality
(%
)
Years2001 2002 2003 2004 2005 2006
40-5940 69-79
80
Age
Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26
NCDR Trends : Age and PCI Mortality
Overall PCI Patients= 1.22%Overall PCI Patients= 1.22%
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4M
ort
ality
(%
)
Years2001 2002 2003 2004 2005 2006
Elective PCI PatientsElective PCI Patients
40-5940 69-79
80
Age
Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26
NCDR Trends : Age and PCI Mortality
0
1
2
3
4
5
6
7M
ort
ality
(%
)
Years2001 2002 2003 2004 2005 2006
Urgent/Emergent/Salvage PCI PatientsUrgent/Emergent/Salvage PCI Patients
40-5940 69-79
80
Age
Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26
NCDR Trends : Age and PCI Mortality
Society of Thoracic Surgery Risk Calculator
• STS National Database website:•www.sts.org/sections/stsnationaldatabase/riskcalculator/
• 85 yo, female, African-American, isolated first time CABG, 80kg, Diabetic on insulin, Creatinine 2.2, mild COPD, HX of Cerebrovascular Disease, no CVA, small NSTEMI, mild CHF, Chronic Atrial Fibrillation, 3 vessel/LMCA disease, 40% ejection fraction, moderate MR, mild TR, mild AS
•
Society of Thoracic Surgery Risk Calculator
• 85 yo female small NSTEMI for isolated CABG• Mortality 27%• 70% Morbidity or Mortality• 61% Increased length of stay• 57% Prolonged ventilation• 47% Renal failure 19% Reoperation Rate• 10% Permanent stroke• 2.2% Deep Sternal Wound
0
2
4
6
8
10
12
<50 55 60 65 70 75 80 85 90+
STS NCN VA NY State NNE CCP
Acute Risks: CABG Mortality
Cheitman M, et alAm J Geritri Cards 2001;10:207-223 Cheitman M, et alAm J Geritri Cards 2001;10:207-223
Revascularization in Older Persons with Chronic CADRevascularization in Older Persons with Chronic CAD
Appropriate Use CriteriaAppropriate Use Criteria
J Am Coll Cardiol 2009; 53;530-553
Available at http://www.acc.org
What are Appropriateness Use Criteria?
What are Appropriateness Use Criteria?
• Define “what to do”, “when to do”, and “how often to Define “what to do”, “when to do”, and “how often to do” in the context of local care environments combined do” in the context of local care environments combined with patient and family preferences and valueswith patient and family preferences and values
• Address misuse, overuse and underuseAddress misuse, overuse and underuse• Connected to guideline content Connected to guideline content • Imply a level of detail and complexity that extends Imply a level of detail and complexity that extends
beyond the current recommendationsbeyond the current recommendations
• Define “what to do”, “when to do”, and “how often to Define “what to do”, “when to do”, and “how often to do” in the context of local care environments combined do” in the context of local care environments combined with patient and family preferences and valueswith patient and family preferences and values
• Address misuse, overuse and underuseAddress misuse, overuse and underuse• Connected to guideline content Connected to guideline content • Imply a level of detail and complexity that extends Imply a level of detail and complexity that extends
beyond the current recommendationsbeyond the current recommendations
Appropriateness Use Criteria Appropriateness Use Criteria Modified Rand/Delphi Modified Rand/Delphi
MethodologyMethodology
Appropriateness Use Criteria Appropriateness Use Criteria Modified Rand/Delphi Modified Rand/Delphi
MethodologyMethodology
The WritingCommittee
Define “Appropriateness” for Coronary Revascularization
“ “Coronary revascularization is appropriate when the Coronary revascularization is appropriate when the expected benefits, in terms of survival or health expected benefits, in terms of survival or health outcomes (outcomes (symptoms, functional status, and/or quality symptoms, functional status, and/or quality of lifeof life) exceed the expected negative consequences of ) exceed the expected negative consequences of the procedure”the procedure”
“ “Coronary revascularization is appropriate when the Coronary revascularization is appropriate when the expected benefits, in terms of survival or health expected benefits, in terms of survival or health outcomes (outcomes (symptoms, functional status, and/or quality symptoms, functional status, and/or quality of lifeof life) exceed the expected negative consequences of ) exceed the expected negative consequences of the procedure”the procedure”
Framework for Decision Making Five Core Variables
Framework for Decision Making Five Core Variables
SY
MP
TO
MS
YM
PT
OM
SSST
AB
ILIT
ST
AB
ILIT
YY ISC
HE
MI
ISC
HE
MI
AA
ME
DIC
AL
M
ED
ICA
L
Rx
Rx A
NA
TA
NA
TO
MY
OM
Y
Stable angina
STEMISTEMI
Class IASx
Class IVClass IV
NoneLow risk
HighHighriskrisk
None
MaxMax
No sig.CAD
LM +LM +3v CAD3v CAD A
U
I
Clinical Scenarios – Patients without prior CABGClinical Scenarios – Patients without prior CABG
CTO of 1 v (in the absence of other disease)or 1-2 v disease (no LAD)
Asymptomatic or low risk noninvasive findingsU I=
RevascularizationRevascularization
Shared Decision-makingShared Decision-making
• Collaboration in decision-making between Collaboration in decision-making between physician and patientphysician and patient
• Physician’s role: Communicate information on Physician’s role: Communicate information on harms/benefits of test or treatmentharms/benefits of test or treatment
• Patient’s role: To provide information about Patient’s role: To provide information about values, preferences, lifestyle, beliefs values, preferences, lifestyle, beliefs
• Goal: Treatment decisions are evidence-based Goal: Treatment decisions are evidence-based and are reflective of the patient’s values and and are reflective of the patient’s values and preferences preferences
• Collaboration in decision-making between Collaboration in decision-making between physician and patientphysician and patient
• Physician’s role: Communicate information on Physician’s role: Communicate information on harms/benefits of test or treatmentharms/benefits of test or treatment
• Patient’s role: To provide information about Patient’s role: To provide information about values, preferences, lifestyle, beliefs values, preferences, lifestyle, beliefs
• Goal: Treatment decisions are evidence-based Goal: Treatment decisions are evidence-based and are reflective of the patient’s values and and are reflective of the patient’s values and preferences preferences
Willingness to Consider an Invasive Cardiac Procedure by Age
505560
6570758085
9095
100
45-59 60-69 70-79 80+
CATH PCI CABGAlexander K 2006Alexander K 2006
Importance of Quality of Life versus Importance of Quality of Life versus Quantity of LifeQuantity of Life
“ “ It is with the elderly that some of the contradictions of modern It is with the elderly that some of the contradictions of modern
medicine are cast in clearest relief. medicine are cast in clearest relief.
…….It is a rare older individual who has not accepted his or her .It is a rare older individual who has not accepted his or her
mortality. In this light, the concept of ‘conquering disease’ loses mortality. In this light, the concept of ‘conquering disease’ loses
some of its romance.”some of its romance.”- - James Goodwin MDJames Goodwin MD
Goodwin, JAMA, 1997
“What are the most important goals from the treatment of your heart disease?”
0
10
20
30
40
50
60
70
80
45-59 60-69 70-79 80+
Lengthen Life Maintain Mental Ability Maintain Independence
Patient CasePatient Case
• Ischemic burden on stress testingIschemic burden on stress testing• Medical therapy optionsMedical therapy options• PCI and CABG optionsPCI and CABG options• Expectation for relief from angina for eachExpectation for relief from angina for each• ““Customized” to patient’s needs and valuesCustomized” to patient’s needs and values
• Ischemic burden on stress testingIschemic burden on stress testing• Medical therapy optionsMedical therapy options• PCI and CABG optionsPCI and CABG options• Expectation for relief from angina for eachExpectation for relief from angina for each• ““Customized” to patient’s needs and valuesCustomized” to patient’s needs and values
85 year old female, small NSTEMI, 3 vessel disease
• Advanced CAD is increasingly a greater challenge in CV Advanced CAD is increasingly a greater challenge in CV medicinemedicine– High morbidity and mortalityHigh morbidity and mortality
• The elderly and those with advanced CAD should receive The elderly and those with advanced CAD should receive evidenced based treatment strategies in ACSevidenced based treatment strategies in ACS– Appropriate medical therapies are underusedAppropriate medical therapies are underused– A targeted invasive approach may be of benefit, if focused on A targeted invasive approach may be of benefit, if focused on
quality of lifequality of life
• A multi-disciplinary approach is required that involves A multi-disciplinary approach is required that involves physical and emotional supportphysical and emotional support
Advanced Coronary Heart Disease: Scope of the Problem in an Aging Population
Advanced Coronary Heart Disease: Scope of the Problem in an Aging Population
ConclusionsConclusions
Evidence-basedTherapies
Evidence-basedTherapies
PersonalizedCare
PersonalizedCare
Evidence-based Guidelines & Patients with Multiple ConditionsEvidence-based Guidelines & Patients with Multiple Conditions
A Balancing Act in Older PersonsA Balancing Act in Older Persons
Evidence-based Guidelines & Patients with Multiple ConditionsEvidence-based Guidelines & Patients with Multiple Conditions
A Balancing Act in Older PersonsA Balancing Act in Older Persons