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Niccolò Marchionni
Ordinario di Geriatria, Università di Firenze
Direttore Dipartimento Cardiotoracovascolare
AOU Careggi, Firenze
La cardiopatia ischemica [angina stabile] nell’anziano e nel grande anziano:
età, comorbilità, politerapia, fragilità
Prevalence of angina pectoris by age and sex (NHANES: 2011–2014)
Benjamin EJ et al. Circulation. 2017;135:e146-e603
2954-2996: 42 pages
10 voci bibliografiche. La più recente del 2004! 32 pages
Diagnostic management of patients with suspected stable CAD
JAMA Intern Med. 2014
42 patients !
Disability, more than multimorbidity, was predictive of mortality among older persons aged 80 years and older
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
0 1 2 3 4
No disability - no comorbidity
No disability - comorbidity (2 diseases)
No disability - comorbidity (3+ diseases)
Disability - no comorbidity
Disability - comorbidity (2 diseases)
Disability - comorbidity (3+ diseases)
Years
Su
rviv
al
rate
Landi F et al. J Clin Epidemiol. 2010
No Disability
Disability
Frailty concept: two 78-year-old patients with severe degenerative mitral valve regurgitation and comparable Logistic Euro-Score (12%)
J Thorac Cardiovasc Surg. 2014;148:3117-8
Short Physical Performance Battery (SPPB)
4-m walking test
Time to walk 4 meters at usual
pace: ____sec
(better of 2 trials)
<4.8 sec 4 scores
4.8-6.2 sec 3 scores
6.3-8.7 sec 2 scores
>8.7 sec 1 score
unable 0 scores
0 1 2 3 4 m
Stand-up and sit down 5 times as
rapidly as possible with arms
crossed
<11.2 sec 4 scores
11.2-13.7 sec 3 scores
13.8-16.7 sec 2 scores
16.8-60 sec 1 scores
>60 sec or unable 0 scores
5 chair standing
Total score: 0-12
Guralnik et al, J Gerontol 1994
Side-by-side
for 10 sec 1 point
Semi-tandem
for 10 sec 1 point
Tandem
tempo:____ sec
for 10 sec 2 points
3-9.9 sec 1 point
<3 sec 0 points
time:____ sec
<10 sec 0 points
time:____ sec
<10 sec 0 points
Standing balance
YES
YES
NO
NO
Prognostic impact of SPPB in older patients hospitalized for CHF
Chiarantini D, et al. J Card Fail 2010
HR (95% CI) p value
SPPB 0.001*
0 6.1 (2.2-16.8) 0.001
1-4 4.8 (1.6-14.0) 0.004
5-8 2.0 (0.7-5.7) 0.223
9-12 Ref. −
Sex (M vs. F) 1.2 (0.7-2.0) 0.583
Age (years) 0.98 (0.94-1.02) 0.355
Site (Ferrara vs. Florence)
1.9 (0.7-5.4) 0.216
LVEF (%) 0.97 (0.95-0.99) 0.005
CIRS-C 1.5 (1.1-1.98) 0.004
NYHA class 1.5 (1.1-2.2) 0.022
* For trend MMSE, depression, drug therapy and previous functional status deleted stepwise
YES
YES
NO YES
NO
• stress imaging, as well as stress ECG, might be challenging in the elderly, while functional capacity often is compromised from muscle weakness
[i.e.: frailty !] and deconditioning
• more frequent false-negative and false-positive results
• despite these differences, exercise stress testing remains important in the elderly and should remain the initial test in evaluating elderly patients with suspected CAD ...
• a stress test provides important prognostic information: a negative test on medical therapy indicates a good 1-year prognosis, such that these patients can be managed medically
Decline in Nuclear MPI
McNulty et al. JAMA 2014; 311:1248-9.
+ 41 - 51
YES
YES
NO YES
NO NO
Eur Heart J 2013
YES
YES
NO YES
NO NO
CONSERVATIVE STRATEGY
«OMT»
INVASIVE STRATEGY
«CORO + RIVASC + OMT»
1970s-1980s CABG vs. “Medical Therapy” (no CABG)
1990s-2000s PCI (BMS) vs. “Some” Medical Therapy
2000s “Optimal” revasc vs. “Optimal” Medical Therapy
Randomized Clinical Strategy Trials in
Stable Ischemic Heart Disease
2007 Courage
2009 Bari 2D
2012 Fame 2
• DES were used in 31 patients (2.7%) in COURAGE • DES were used in 1/3 of PCI patients in the BARI 2D
• 32% cross-over from OMT during FU in COURAGE • 46% cross-over from OMT during FU in BARI 2D
MAIN STUDIES LIMITATIONS
NON Optimal revascularization
High % of revasc in the OMT groups during FU
Low risk patients • Ischemia non mandatory for enrollment • Patients enrolled after cath
COURAGE & BARI 2D
FAME 2 randomized patients after cath; physicians treating medical therapy patients knew the anatomy and FFR results
No difference in death or MI. If primary endpoint of COURAGE and BARI 2D included revascularization procedures, there would have been significant ∆ between arms
Success of medical therapy/risk factor control not reported
FAME 2
But, most importantly ...
… are these results applicable to “real world” over75 patients?
COURAGE BARI 2D FAME 2
AGE (yrs) 61.5 62.4 63.5
Female 15 30 23
Hypertension 66 ? 78
Diabetes 33 100 27
CKD 16 pazienti con filtrato <30 ml/min
? (EC creatinine >2
mg/dL)
2 % ( 20 pz con creatinina >2 mg/dL)
POAD ? 22 10
EF 61 57 ?
Lancet 2001; 358: 951–957
August , 2011
75 +? 14 %
March, 2017
Elderly patients with objective evidence of significant ischaemia at non-invasive testing should have the same access to OMT or coronary arteriography as younger patients
Medical management of patients with stable coronary artery disease
Prescription of evidence-based medication for secondary prevention varied with age, with patients ≥75 years treated less often with beta blockers, aspirin and angiotensin-converting enzyme inhibitors than patients <65 years.
Int J Cardiol 2013
OUTPATIENTS DIAGNOSTIC TESTS
LOCAL HEALTH UNITS BENEFICIARIES
PHARMACY CLAIMS
• prescribed drug
• date of prescription
• drug price
• nr. of packages
• dose
• type of service
• date of service
• cost of service
POPULATION DATABASE
• date of birth • gender • life status
patient’s code patient’s code patient’s code
Linkage of data from 4 administrative databases over 5 years (2006-2010)
HOSPITAL DISCHARGE
• main diagnosis
• secondary diagnosis
• type of hospitalization
• date of admission
• DRG payment
patient’s code
anonymous patient’s code
Exploring administrative databases to assess the impact of appropriate prescriptions &
adherence on health outcomes
The case of myocardial infarction: a practical exercise analysis
Discharge date of hospitalization for AMI (index-date)
Recruitment period (2 years)
Characterization period (1 year preceding the index-date)
Observation period (1 year following index-date)
01/01/2009 31/12/2009 01/01/2007
FU analysis (antiplatelets, ACE/Ang2-inhibitors, statins, b-blockers)
01/01/2006
Inclusion criteria • persons aged 65 yrs or more on 01/01/2007 (n = 592,160)
• discharged with AMI* (ICD9 : 410.) as principal diagnosis during the recruitment period
Exclusion criteria
• persons with previous hospital admission for cardiovascular disease during the characterization period
• antiplatelet or anticoagulant agents during the characterization period
• death or moving away during the observation period (for the drug consumption analysis)
01/01/2008
Intern Emerg Med. 2016;11:677-85. doi: 10.1007/s11739-016-1391-0
N = 2,626
56 % men
25 % 85+ years
Intern Emerg Med. 2016;11:677-85. doi: 10.1007/s11739-016-1391-0
Intern Emerg Med. 2016;11:677-85. doi: 10.1007/s11739-016-1391-0
Conclusions:
Enhancing compliance with treat-
ment guidelines may reduce the
burden of mortality and hospitaliza-
tions in older MI survivors
Am J Cardiol. 2016 Dec 1;118(11):1624-1630. doi: 10.1016/j.amjcard.2016.08.042
N = 2,597
45 % men
83.9 7.4 years
Conclusions:
In community-dwelling older patients
with CAD, statin treatment is associated
with reduced 3-year mortality irrespe-
ctive of age and multidimensional
impairment, though frailest patients are
less likely to be treated
Angina stabile nel grande anziano
[… tra mancanza di dati e miti da sfatare …]
• Nonostante la prevalenza di angina cresca con l’età, le linee-guida riservano agli anziani uno spazio molto ridotto
• Ciò riflette la carenza di evidenze età-specifiche su tutti gli snodi decisionali, dalla diagnosi al trattamento
• Nuove evidenze sulla gestione terapeutica devono essere costruite con RCT che includano over75 fragili (da definire!) e comorbosi, abitualmente esclusi dai trial
• Studi di registro «real world» suggeriscono che anche i molto anziani con CAD e condizioni cliniche complesse beneficiano del trattamento in prevenzione secondaria raccomandato dalle linee-guida
Conclusioni