LA PATOLOGIA CORONARICA NELL’ANZIANO

Ruolo della VMD nella selezione del paziente anziano da sottoporre a

rivascolarizzazione

Samuele Baldasseroni

……We found that there is a pervasive lack ofevidence to guide clinical decision making inolder patients with cardiovascular disease, aswell as a paucity of data on the impact of diagnosticand therapeutic interventions on key outcomes thatare particularly important to older patients, such asquality of life, physical function, and maintenance ofindependence……………..

JACC 24 Th may 2016

…. Perché mancano le evidenze ?..

Anziano malato di cuore

Anziano malato ANCHE di cuore

…. COMPLESSITA’ …..

DisabilitàFisica

cogntiva ComorbositàCVS e non CVS

Fragilitàe pre-fragilità

Fried L, et al. J Gerontol 2001

…. COMPLESSITA’ Cardiologica che risiede…..

….Nei piu complessimeccanismi fisiopatologici…

…nelle difficoltà dell’approccioclinico-terapeutico….

…nelle nostre capacitàdi stratificazione prognostica….

RUOLO della VALUTAZIONE MULTIDIMENSIONALE GERIATRICA nell’ ANZIANO cardiopatico

Strumento di stratificazione prognostica

Strumento per influenzare il decision-making

Strumento per identificazione outcomes

VMD come stratificatore prognostico

Nel angioplasticapercutanea

Nel by-pass Aorto-coronarico

Conclusions—Frailty is stronglyand independently associatedwith in-hospital mortality, 1-month mortality, prolongedhospital care, and the primarycomposite outcome.The combined use of frailty andcomorbidity may constitute anultimate risk prediction conceptin regard to cardiovascularpatients with complex needs

Circulation. 2011;124:2397-2404.)

Medical T vs

Reperfusion T

…… we believe that the present analysishighlighted to what extent long-term mortality afterSTEMI is affected by therapeutic choices in the acutephase that are linked to the presence of comorbidconditions. Analysis also confirmed the need forenriching the training of medical specialists to targetfrail, often old, individuals presenting with acutecoronary syndromes and a relevant burden of chroniccomorbidity……………….

VMD e decision making nell’anziano coronaropatico

Decision-making process

Procedura di rivascolarizzazione

Cardiac surgery as a stressor and the response of the vulnerable older adults

Neupane I, Arora R, Rudolph JL 2016 in press

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…..vulnerabilities in biological, psychological, and social domains can limit recovery after the stress of cardiac surgery. Identification of vulnerability in these domains can allow better understanding of the risks of cardiac surgery and tailoring of interventions to improve outcomes……

Concetto fondamentale=TAILORING THE INTERVENTION

This study is one of the first to describethe different frailty trajectories forpatients with CAD undergoing differentapproaches to their therapy. We foundthat frailty was more dynamic in frailerpatients in this group. …..In our sample,frailty followed a U-shaped curve afterrevascularization. However, relativelyolder patients (aged ≥75 years) initiallyassigned to MT or CABG did notexperience this temporary decrease(orimprovement). They showed continuousincreases in their frailty level frombaseline during the 30 months. Ifconfirmed by other studies, frailtytrajectories could be used to informindividualized decision making aboutinitial treatment choices and allow moretailored subsequent patientcare and monitoring once effectivetherapeutic approacheshave been demonstrated.

Anziano

Geriatrician

Modificata, GIC 2016

VMD e outcomes definitionnell’anziano coronaropatico

Cardiac Surgery patient

It is not just survival, but the relief ofsymptoms, avoidance of long-termdisability, and a sense of well-beingthat are likely to be the mostimportant and highly valued outcomesfor patients undergoing major surgery

Disability-free survival, therefore, seemsto satisfy the key criteria for an idealoutcome measure after cardiac surgery. Itaddresses the primary aims of mostcardiac surgery: reduced symptomsand/or improved healthy survival. It isclearly a patient-centered outcome. Thequestion then becomes: how would ourpatients define disability and how shouldit be quantified after cardiac surgery?

Patient centered-outcome

Duration of disability

Time of Cardiac procedure

Disability free survival

CONCLUSION: ….These results suggest that AF is a risk factor for shorter functional longevity in older adults, independent of other risk factors and comorbidconditions.

Take on messages1. L’utilizzo della VMD nella startificazione prognostica dell’ anziano

complesso con coronaropatia comincia a ritagliarsi le sueevidenze via via sempre piu solide e apprezzate anche dallacomunità dei cardiologi

2. Il peso della valutazione geriatrica nel decision makingdiagnostico terapeutico sulle nuove tecniche di cura

interventistiche cardiologiche nel paziente anziano rimane allostato attuale molto basso ma sembra esserecomunque fondamentale

3. Dobbiamo spingere la comunità scientifica ha costruire studi conoutcomes geriatrici, perchè sono gli anziani che lo chiedono, e

uno di questi sembra indiscutibilmente la sopravvivenzalibera da disabilità

Grazie per l’attenzione