Downloaded from http://heart.bmj.com/ on November 9, 2014 - Published by group.bmj.com
Editorial
Increased risk and increased reward in coronary intervention in older patients with acute coronary syndrome Ramesh Mazhari,1 Navin Kapur2 In the USA, among patients 65 years or younger, 75% of those with acute coronary syndrome (ACS) receive percutaneous coronary intervention (PCI) according to the National Registry for Myocardial Infarction (NRMI).1 These high figures contrast markedly with PCI rates among older patients. In the elderly population, only 40% of patients older than 75 years of age receive reperfusion therapy.1 Somewhat consistent with these low US figures, a recent study in England found an incremental reduction in the use of invasive and medical therapies with increasing age.2 The current American College of Cardiology/AHA guidelines and ESC guidelines do not suggest any age limitation in the use of PCI in management of ACS.3 4 The ESC guidelines suggest that the invasive strategy and PCI show increased benefit in older patients.4 The randomised clinical trials, however, provide limited data in relation to management of ACS in elderly patients. Most of the large PCI trials specifically excluded older patients, and when all clinical trials are considered, only about 9% of enrolled patients are older than 75 years, where in actual clinical practice about 35% of patients presenting with ACS are older than 75 years.1 In addition, the baseline characteristics of the older patients in clinical trials are different from the older population in the community.4 The patients in the community tend to be older, more heterogeneous with more comorbidity.5 Largely as a result of this downward skewing of study populations relative to the actual clinical population, the evidence-based practice guidelines do not reflect the real-life practice of cardiology and may not provide adequate guidance for how to treat elderly patients with ACS. Partly because of this lack of adequate guidance, clinicians appear to make informal estimations of the relative risks and benefits of PCI in elderly 1
Department of Cardiology, George Washington University, Washington, DC, USA; 2Tufts, Boston, USA Correspondence to Dr Ramesh Mazhari, Department of Cardiology, George Washington University, Washington, DC, USA; [email protected]
patients, which results in markedly reduced rates of PCI among elderly patients with ACS. A preoccupation with the risk of complications seems to lie behind these low rates of PCI among the elderly. This preoccupation is not without basis. According to the National Heart Lung and Blood Institute’s Dynamic Registry, patients older than age 80 years are more likely to have threevessel coronary disease, and higher burden of coronary calcification, requiring multivessel PCI, which translates into higher procedural risk. These characteristics translate into higher risk of procedural and postprocedural complications. The procedural risk is secondary to a higher likelihood of multivessel coronary artery disease and to an increased prevalence of comorbidities. Postprocedurally, a prospective registry study of patients >85 years of age reported higher rates of unadjusted mortality, postprocedural myocardial infarction, and of renal, neurological and access-site complications, in patients older than 85 years; these complications are especially common among patients undergoing non-elective procedures.6 Notwithstanding the greater risks, current evidence suggests considerable value in PCI for elderly patients with ACS.2 In terms of clinical outcomes, several studies have already demonstrated that although the benefit from invasive strategies are attenuated in older age groups, there remains a mortality benefit from invasive strategies compared with conservative management of ACS.4 The technical success rate in patients over the age of 80 years is reported to be 93%, according to the American College of Cardiology-National Cardiovascular Data Registry. The reported risk of intervention in older patients does not reflect the recent advances in the technology and improvements in the procedural methods. For example, there has been increased utilisation of transradial approach for coronary procedures.7 This method has been shown to be feasible in elderly patients, and reduces the risk of access site bleeding complications.7 Thus, there is reason to suspect that the much lower rates of PCI in elderly patients with myocardial
Mazhari R, et al. Heart October 2014 Vol 100 No 19
infarction should be scrutinised and considered for re-evaluation. It is important to identify the factors that will impact the underutilisation of PCI in older population. The large registry data, which reflect the real world practice, is a valuable source to identify the factors associated with underuse of PCI in elderly. Di Bari and colleagues8 used the data from AMI-Florence registry in this observational study to identify the variables predicting clinical prognosis and utilisation of invasive strategies in patients older than 75 years of age. In this study, comorbidities and global health status were used as numerical variables called comorbidity score and Silver Code (SC) score respectively. The investigators found that the application of PCI was diminished by 11% per each point increase in the SC score. They also found that PCI was more effective in patients with the higher SC score. The introduction of SC score as a prognostic variable in this study is an important step in recognising that in the older population, the risk models should include other non-medical comorbidities. SC score includes the patient’s marital status, the number of recent admissions to the hospital, and the number of medications. This score reflects the patients’ overall health status and potential for recovery. There are limited tools available for risk stratification of elderly patients with ACS. The current risk models, such as Mayo Clinic Risk Score, include age and medical comorbidities to establish a score that predicts outcome after PCI.9 The numerical age per se does not adequately reflect the extent of frailty in this population. Frailty is measured using the Fried and Walston definition, and includes five criteria of unintended weight loss (>10 lb in the preceding year), exhaustion, physical activity, time required to walk 15 feet, and grip strength. Adding frailty to the traditional cardiovascular risk score improves the predictive accuracy of this model in older patients following coronary interventions.9 A risk assessment model, which includes frailty in addition to medical comorbidities, will be of great value in risk stratification of elderly patients presenting with ACS and decisions to consider coronary intervention in the geriatric population. The recent advances in interventional techniques have opened a new chapter in the care of elderly patients with advanced cardiovascular disease. In the landmark trial of transcatheter aortic valve implantation for severe aortic stenosis, the mean
1483
Downloaded from http://heart.bmj.com/ on November 9, 2014 - Published by group.bmj.com
Editorial age of the participants was 83years and the survival benefit in this trial has introduced a new paradigm in care of the geriatric population. Future randomised trials to examine the safety and efficacy of PCI in patients older than 75 years, along with using comprehensive risk assessment models can guide the risk stratification and management of elderly patients with ACS. Contributors RM, is the first author of this editorial and has contributed to writing the text and researching the material. NK has provided input into the subject material and edited the content of the editorial.
5
▸ http://dx.doi.org/10.1136/heartjnl-2013-305445 Heart 2014;100:1483–1484. doi:10.1136/heartjnl-2014-306134
REFERENCES 1
2
Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Mazhari R, Kapur N. Heart 2014;100:1483– 1484. Published Online First 19 June 2014
1484
3
4
Alexander KP, Roe MT, Chen AY, et al. Evolution in cardiovascular care for elderly patients with non-STsegment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative. J Am Coll Cardiol 2005;46:1479–87. Zaman MJ, Stirling S, Shepstone L, et al. The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP). Eur Heart J 2014. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362–425. Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in
6
7
8
9
patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007;115: 2549–69. Appleby CE, Ivanov J, Mackie K, et al. In-hospital outcomes of very elderly patients (85 years and older) undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2011;77:634–41. Gutierrez A, Tsai TT, Stanislawski MA, et al. Adoption of transradial percutaneous coronary intervention and outcomes according to center radial volume in the Veterans Affairs Healthcare system: insights from the Veterans Affairs clinical assessment, reporting, and tracking (CART) program. Circ Cardiovasc Interv 2013;6:336–46. Di Bari M, Balzi D, Fracchia S, et al. Decreased usage and increased effectiveness of percutaneous coronary intervention in complex older patients with acute coronary syndromes. Heart 2014;100:1537–42. Singh M, Rihal CS, Lennon RJ, et al. Influence of frailty and health status on outcomes in patients with coronary disease undergoing percutaneous revascularization. Circ Cardiovasc Qual Outcomes 2011;4:496–502.
Mazhari R, et al. Heart October 2014 Vol 100 No 19
Downloaded from http://heart.bmj.com/ on November 9, 2014 - Published by group.bmj.com
Increased risk and increased reward in coronary intervention in older patients with acute coronary syndrome Ramesh Mazhari and Navin Kapur Heart 2014 100: 1483-1484 originally published online June 19, 2014
doi: 10.1136/heartjnl-2014-306134 Updated information and services can be found at: http://heart.bmj.com/content/100/19/1483
These include:
References Email alerting service
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This article cites 7 articles, 5 of which you can access for free at: http://heart.bmj.com/content/100/19/1483#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Drugs: cardiovascular system (7920) Acute coronary syndromes (2494) Epidemiology (3265) Interventional cardiology (2682) Percutaneous intervention (877)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Editorial
Increased risk and increased reward in coronary intervention in older patients with acute coronary syndrome Ramesh Mazhari,1 Navin Kapur2 In the USA, among patients 65 years or younger, 75% of those with acute coronary syndrome (ACS) receive percutaneous coronary intervention (PCI) according to the National Registry for Myocardial Infarction (NRMI).1 These high figures contrast markedly with PCI rates among older patients. In the elderly population, only 40% of patients older than 75 years of age receive reperfusion therapy.1 Somewhat consistent with these low US figures, a recent study in England found an incremental reduction in the use of invasive and medical therapies with increasing age.2 The current American College of Cardiology/AHA guidelines and ESC guidelines do not suggest any age limitation in the use of PCI in management of ACS.3 4 The ESC guidelines suggest that the invasive strategy and PCI show increased benefit in older patients.4 The randomised clinical trials, however, provide limited data in relation to management of ACS in elderly patients. Most of the large PCI trials specifically excluded older patients, and when all clinical trials are considered, only about 9% of enrolled patients are older than 75 years, where in actual clinical practice about 35% of patients presenting with ACS are older than 75 years.1 In addition, the baseline characteristics of the older patients in clinical trials are different from the older population in the community.4 The patients in the community tend to be older, more heterogeneous with more comorbidity.5 Largely as a result of this downward skewing of study populations relative to the actual clinical population, the evidence-based practice guidelines do not reflect the real-life practice of cardiology and may not provide adequate guidance for how to treat elderly patients with ACS. Partly because of this lack of adequate guidance, clinicians appear to make informal estimations of the relative risks and benefits of PCI in elderly 1
Department of Cardiology, George Washington University, Washington, DC, USA; 2Tufts, Boston, USA Correspondence to Dr Ramesh Mazhari, Department of Cardiology, George Washington University, Washington, DC, USA; [email protected]
patients, which results in markedly reduced rates of PCI among elderly patients with ACS. A preoccupation with the risk of complications seems to lie behind these low rates of PCI among the elderly. This preoccupation is not without basis. According to the National Heart Lung and Blood Institute’s Dynamic Registry, patients older than age 80 years are more likely to have threevessel coronary disease, and higher burden of coronary calcification, requiring multivessel PCI, which translates into higher procedural risk. These characteristics translate into higher risk of procedural and postprocedural complications. The procedural risk is secondary to a higher likelihood of multivessel coronary artery disease and to an increased prevalence of comorbidities. Postprocedurally, a prospective registry study of patients >85 years of age reported higher rates of unadjusted mortality, postprocedural myocardial infarction, and of renal, neurological and access-site complications, in patients older than 85 years; these complications are especially common among patients undergoing non-elective procedures.6 Notwithstanding the greater risks, current evidence suggests considerable value in PCI for elderly patients with ACS.2 In terms of clinical outcomes, several studies have already demonstrated that although the benefit from invasive strategies are attenuated in older age groups, there remains a mortality benefit from invasive strategies compared with conservative management of ACS.4 The technical success rate in patients over the age of 80 years is reported to be 93%, according to the American College of Cardiology-National Cardiovascular Data Registry. The reported risk of intervention in older patients does not reflect the recent advances in the technology and improvements in the procedural methods. For example, there has been increased utilisation of transradial approach for coronary procedures.7 This method has been shown to be feasible in elderly patients, and reduces the risk of access site bleeding complications.7 Thus, there is reason to suspect that the much lower rates of PCI in elderly patients with myocardial
Mazhari R, et al. Heart October 2014 Vol 100 No 19
infarction should be scrutinised and considered for re-evaluation. It is important to identify the factors that will impact the underutilisation of PCI in older population. The large registry data, which reflect the real world practice, is a valuable source to identify the factors associated with underuse of PCI in elderly. Di Bari and colleagues8 used the data from AMI-Florence registry in this observational study to identify the variables predicting clinical prognosis and utilisation of invasive strategies in patients older than 75 years of age. In this study, comorbidities and global health status were used as numerical variables called comorbidity score and Silver Code (SC) score respectively. The investigators found that the application of PCI was diminished by 11% per each point increase in the SC score. They also found that PCI was more effective in patients with the higher SC score. The introduction of SC score as a prognostic variable in this study is an important step in recognising that in the older population, the risk models should include other non-medical comorbidities. SC score includes the patient’s marital status, the number of recent admissions to the hospital, and the number of medications. This score reflects the patients’ overall health status and potential for recovery. There are limited tools available for risk stratification of elderly patients with ACS. The current risk models, such as Mayo Clinic Risk Score, include age and medical comorbidities to establish a score that predicts outcome after PCI.9 The numerical age per se does not adequately reflect the extent of frailty in this population. Frailty is measured using the Fried and Walston definition, and includes five criteria of unintended weight loss (>10 lb in the preceding year), exhaustion, physical activity, time required to walk 15 feet, and grip strength. Adding frailty to the traditional cardiovascular risk score improves the predictive accuracy of this model in older patients following coronary interventions.9 A risk assessment model, which includes frailty in addition to medical comorbidities, will be of great value in risk stratification of elderly patients presenting with ACS and decisions to consider coronary intervention in the geriatric population. The recent advances in interventional techniques have opened a new chapter in the care of elderly patients with advanced cardiovascular disease. In the landmark trial of transcatheter aortic valve implantation for severe aortic stenosis, the mean
1483
Downloaded from http://heart.bmj.com/ on November 9, 2014 - Published by group.bmj.com
Editorial age of the participants was 83years and the survival benefit in this trial has introduced a new paradigm in care of the geriatric population. Future randomised trials to examine the safety and efficacy of PCI in patients older than 75 years, along with using comprehensive risk assessment models can guide the risk stratification and management of elderly patients with ACS. Contributors RM, is the first author of this editorial and has contributed to writing the text and researching the material. NK has provided input into the subject material and edited the content of the editorial.
5
▸ http://dx.doi.org/10.1136/heartjnl-2013-305445 Heart 2014;100:1483–1484. doi:10.1136/heartjnl-2014-306134
REFERENCES 1
2
Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Mazhari R, Kapur N. Heart 2014;100:1483– 1484. Published Online First 19 June 2014
1484
3
4
Alexander KP, Roe MT, Chen AY, et al. Evolution in cardiovascular care for elderly patients with non-STsegment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative. J Am Coll Cardiol 2005;46:1479–87. Zaman MJ, Stirling S, Shepstone L, et al. The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP). Eur Heart J 2014. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362–425. Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in
6
7
8
9
patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007;115: 2549–69. Appleby CE, Ivanov J, Mackie K, et al. In-hospital outcomes of very elderly patients (85 years and older) undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2011;77:634–41. Gutierrez A, Tsai TT, Stanislawski MA, et al. Adoption of transradial percutaneous coronary intervention and outcomes according to center radial volume in the Veterans Affairs Healthcare system: insights from the Veterans Affairs clinical assessment, reporting, and tracking (CART) program. Circ Cardiovasc Interv 2013;6:336–46. Di Bari M, Balzi D, Fracchia S, et al. Decreased usage and increased effectiveness of percutaneous coronary intervention in complex older patients with acute coronary syndromes. Heart 2014;100:1537–42. Singh M, Rihal CS, Lennon RJ, et al. Influence of frailty and health status on outcomes in patients with coronary disease undergoing percutaneous revascularization. Circ Cardiovasc Qual Outcomes 2011;4:496–502.
Mazhari R, et al. Heart October 2014 Vol 100 No 19
Downloaded from http://heart.bmj.com/ on November 9, 2014 - Published by group.bmj.com
Increased risk and increased reward in coronary intervention in older patients with acute coronary syndrome Ramesh Mazhari and Navin Kapur Heart 2014 100: 1483-1484 originally published online June 19, 2014
doi: 10.1136/heartjnl-2014-306134 Updated information and services can be found at: http://heart.bmj.com/content/100/19/1483
These include:
References Email alerting service
Topic Collections
This article cites 7 articles, 5 of which you can access for free at: http://heart.bmj.com/content/100/19/1483#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Drugs: cardiovascular system (7920) Acute coronary syndromes (2494) Epidemiology (3265) Interventional cardiology (2682) Percutaneous intervention (877)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
