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

• Largest single cause of death in developed world

• Medical therapy

• CABG (Favaloro in 1969)

• PTCA (Gruentzig in 1977)

• Coronary stents (Sigwart in 1989)

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

Mortality (in-hospital) 1.3%

Predictors:» AGE» Co-morbidity» Pre-operative LV function» Surgical parameters» IABP requirement

CABG – MortalityNNECDSG SCORE

• Age + Gender

• LV Ejection Fraction

• Urgency of Surgery

• Previous CABG

• PVD, Diabetes, Renal Failure, COAD

• Body Habitus

NNECDSG scoreMortality score CVA score

Age 60-69 2 3.5

Age 70-79 3 5

Age 80 5 6

Renal dialysis 4 2

Each point = 0.2 – 2 % rise in mortality

CABG – 30 day Mortality

< 70 years > 70 years

All CABG 1.3 % 3.9 %

AVR + CABG 3 % 7.3 %

MVR + CABG 13 % 12.5 %

Emergency surgery

18.4 % 32 %

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 – 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 – 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 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 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

• Most trials performed before:• Stents• Clopidogrel• IIb/IIIa platelet inhibitors

• 447 000 procedures/year in USA (1997)

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

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

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/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

Study from 1980 –1996

< 50 70-79 >80

In-hospital mortality 0.28 % 2.1 % 3.45 %

Q-wave MI 1.6 % 1.0 % 2.54 %

CABG 4.94 % 3.5 % 2.7 %

5 year survival 94 % 76 % 65 %

PTCA stenting Influence of age

< 70 years

1yr 5yrs

70 years

1yr 5yrs

Non Q-wave MI 1.3 % 5.1 % 1.2 % 5.8 %

Severe angina 22.9 % 39.2 % 22.1 % 37.2 %

Repeat PTCA 11.0 % 22.9 % 9.3 % 18.6 %

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• High rate of co-morbidity

40-60% IHD 15-25% COAD 5-25% CVA 20-50% Hypertension

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8

Risk score

Mor

tali

ty (

%)

Age > 80 years

AVR

MVR

Valve surgery in > 80 yrs ageRisk scoreEF: 30-50% +2 EF <30% +5Re-operation +2 Valve & CABG +2

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8

Risk score

Mor

tali

ty (

%)

Age > 80 years

AVR

MVR

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

Symtomatic Aortic Stenosis in the > 80 Year Old

00.10.20.30.40.50.60.70.80.9

1

1 2 3 4 5 6 7 8 9 10

Unselected 80 yearoldsAll patients afterAVR Unoperated patients> 80 Years oldPatients survivingafter AVR

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

• Mortality 0.3%

• Major complication 3%

• Success 85 – 100% (95%)

• Recurrence 2 – 21%

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

• Undoubted prognostic benefit

• Procedural mortality 0.5 – 0.8 %

• Primary prevention

• Secondary 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

• 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

• 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!