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