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Cardiovascular Care of Older Adults:
Acute Myocardial Infarction
Karen P. Alexander MD
Associate Professor Medicine
Duke Clinical Research Institute
Duke University Medical Center
Durham, NC
Outline
• Understand the presentation of ACS in older adults
• Safe and effective therapies for ACS in older adults.
• Assess likely health outcomes among older adults with
ACS
• Appreciate the role of discharge planning in optimizing
medication safety and return to independent functioning.
• Needs for future research
Population Incidence of Heart Disease
Cardiovascular Health Study
Rate/1,000 Person-Years
Caucasian Male: 10 year follow up
Age (Yrs)
CHD = Fatal and Non-fatal MI, Angina, coronary revascularization
REF: Arnold AM, et al, JAGS 2005;53:211-218
Risk Factors for First MI
INTERHEART Case- Control Acute MI; 52 countries; >30,000 pts
Young
Old*
Smoking
3.33 (2.86 - 3.87)
2.44 (2.10 – 2.84)
HTN
2.24 (1.93 – 2.60)
1.72 (1.52 – 1.95)
Diabetes
2.96 (2.40 – 3.64)
2.05 (1.71 – 2.45)
Abdominal Obesity
1.79 ( 1.52 – 2.09)
1.50 (1.29 – 1.74)
Lipids: ApoB/ApoA1
4.35 ( 3.49 – 5.42)
2.50 (2.05 – 3.05)
Fruits and Vegetables
0.69 (0.58 – 0.81)
0.72 (0.61 – 0.85)
Exercise
0.95 (0.79 – 1.14)
0.79 ( 0.66 – 0.94)
Alcohol
1.00 (0.85 – 1.17)
0.85 (0.73 – 1.00)
Psychosocial Stress
2.87 ( 2.19 – 3.77)
2.43 (1.86 – 3.18)
Pop. Attributable Risk
* Old = Men >55 yrs; Women >65 yrs
93.9%
87.9%
REF: Yusuf et al, Lancet 2004;364:937-52
% ≥ 85 years
Age ≥ 85 among the Myocardial Ischemia
National Audit Project (MINAP) Registry
Year
Rosengren EHJ 2012:33:562
MINAP: Final MI Diagnosis
AGE
AGE
Gale, EHJ 2012;33:630-639
1975/78 (REF) – 1993/95
Worcester Heart Attack Study
OR for In-hospital Mortality
Controlling for gender, med history, AMI type, complications
MI Type
QW
NQWMI
Age (yrs)
55-64 65-74 75-84
≥85
(REF)
1975/78
1.0
1.0
1.0
1.0
1.0
1.0
0.89
0.23*
0.55*
0.48*
0.93
Case Fatality = 21%
Median Age = 66 yrs
1993/95
0.33*
Case Fatality = 11%
Median Age = 74 yrs
*Significant
REF: Goldberg, AJC 1998:82:1311-1317; Furman, J ACC 2001;37:1571-80
Time Trends
2003 (REF) – 2011 (MINAP Registry)
OR In-Hospital Mortality By Age
NSTEMI
(2003)
(2010)
Mort. RR
<55 yrs
1.9%
0.9%
0.89 (0.48-1.34)
>85 yrs
31.5%
20.4%
0.56 (0.42-0.73)
STEMI
(2003)
(2010)
Mort. RR
<55 yrs
2.0%
1.5%
0.72 (0.39-1.25)
>85 yrs
30.1%
19.4%
0.56 (0.38-0.75)
Gale, EHJ 2012;33:630-639
MINAP: NSTEMI In-Hospital Mortality
Adj. for Age, DM, HTN, CAD hx, HF, ward (REF: Age <55yr)
Adj. Odd Ratio (95% CI)
MEN
Years
Years
Gale, EHJ 2012;33:630-639
450
400
350
300
250
200
150
100
50
0
10%
Efficacy (RRR)
30
25%
Efficacy (RRR)
25
1 Yr mortality
20
15
10
5
1 year Mortality*
Number Needed to Treat
Mortality and NNT Relationships
0
<50
50-64
65-74
75+
Patient Age (Yrs)
*Mortality Estimates based on AMI patients treated in Ontario from 1997-2000
Alter, AJM, 2004
Applying Guidelines Out of the Box
Trials
Benefits
Risks
62
Age
–
–
–
–
–
Disease Severity
Comorbidity
Community
69
Do they resemble patients in trials?
Is dosing and delivery of treatment similar?
Do conditions of aging dynamically alter treatment effect?
Do treatment risks outweigh benefits?
Do expected outcomes match desired outcomes?
REF: Tinetti, NEJM 2004; 351: 2870-2874
Older Adults: Comorbidity and Dysfunction
50
45
40
% of population
35
CHF
Renal Insuff
Stroke
Frailty*
Cognitive Impairment
30
25
20
15
10
5
0
<65
65-74
75-84
Patient Age
85+
* Frailty: Fatigue, Slow Gait,
Weak Grip, Wt loss >10 lbs,
Low Activity
REFS: JACC 2005;46: 1479-87; CHS J Geront Biol Sci 2001; Canadian Health and Agin
Older Adults: Disability
Canadian Study of Health and Aging
9,008 Community Dwelling Seniors
Basic (physical) and Instrumental (functional) ADLs
REF: Griffith L, et al. Age and Ageing 2010;39:738-745
Frailty Phenotype
Features: Weakness, Muscle Wasting, Cognitive Impairment,
Depression, Nutrition, Isolation, Low Physical Function, Fatigue
Comorbidity
(>2 conditions) 66%
Frailty
Disability
25%
Age
(yrs)
Life Years
Prevalence
>65
>25
~8%
70
19.3
15%
75
11.7
28%
80
8.9
32%
85
6.6
38%
90
4.8
40%
27%
(>1 ADL)
Heterogeneity of Aging
• Biological Phenotype
–
–
–
–
–
Cumulative comorbidity counts
Cognitive Impairment
Disability
Functional Status
Visual and Hearing Impairments
• Physiologic Phenotype
Jeanne Calment
(Photo Age 113)
Lived to 122 years, Arles
France
–
–
–
–
–
↓ Blood vessel integrity and response to injury
↓ Vascular Compliance
D-dimer and inflammatory markers increase
Altered Clotting (low platelet turnover)
↑ Thrombin, Fibrinogen, Factors IX, X
REF: http://entomology.ucdavis.edu/courses/hde19/lecture3.html
Unmasking Narrow Reserves
DECLINES OF
FUNCTION
NSTEMI
CHALLENGES
TO HOMEOSTASIS
• Less resilient to acute disease
• Less resilient to drug effects
Fries, 1981
CAD Limiting Reserves
CHALLENGES
TO HOMEOSTASIS
CAD Treatment
• Cardiac disease was major health limitation
• Treatment enables resumption of function
Fries, 1981
Non-CAD Limiting Reserves
CHALLENGES
TO HOMEOSTASIS
• Underlying comorbidity impairs function
• Non-cardiac disease limits survival
Fries, 1981
Unmasking Narrow Reserves
DECLINES OF
FUNCTION
NSTEMI
CHALLENGES
TO HOMEOSTASIS
• Less resilient to acute disease
• Less resilient to drug effects
Fries, 1981
Older Adults (≥75 y) = Special Population
Presentation Atypical
Under treated (Under studied)
Independent risk Mortality
Independent risk Bleeding
Multiple Coexisting Conditions
Yes
Yes
Yes
Yes
Yes
REF: Anderson J, NSTEMI Guidelines. JACC 2007;50:652–726; Tinetti, NEJM 2004; 351: 2870
Presenting Signs by Age
CRUSADE : Signs of CHF
NRMI 2-4 : EKG non-diagnostic (RBBB or other)
50
45
% Population
40
35
30
Signs of CHF
EKG non-diagnostic
25
20
15
10
5
0
<65 yrs
65-74 yrs
75-84 yrs
Patient Age
>84 yrs
ED Presenting Signs and Symptoms
Chart Review from CRUSADE (n=607)
100
90
80
All P<0.05
<75 Years N=468
>=75 Years N=182
70
60
50
40
30
20
10
0
Chest Pain
Other*
Hypoxia or Tachy
Anemia
*Other: Dizziness, Palpitations, Abdominal Pain, Headache, Altered Mentation
Nursing Home: 10 v. 2% (p<0.01)
Krashnewski, AHA Outcomes Abs. Submitted
Universal MI Definition
Type I: Spontaneous MI
atherosclerotic plaque rupture with
thrombus in one or more of the
coronary arteries.
Type 3: Sudden Death MI
Thrombus
Type 2: Secondary MI
Sudden cardiac death with or without
ECG changes or biomarkers can be
TYPE I
a condition other than CAD
contributes to increased myocardial
oxygen demand or decreased
myocardial blood flow.
obtained.
Type 4/5: Revasc MI
Peri-procedural injury associated with
instrumentation of the heart during
revascularization, either PCI or CABG.
Procedures
TYPE 2
Heart Failure
Anemia
Tachyarrhythmia
Renal Failure
REF: Thygesen K, JACC 2007;27:2173
2011 UA/NSTEMI Guidelines : Special Population Section
I IIa IIb III
I IIa IIb III

Older adults with UA/NSTEMI should be evaluated and
treated for acute and discharge therapies in a similar manner
as younger adults

Attention should be given to adjusting anti-platelet and
anticoagulant doses based on weight and renal function (eg.
estimated creatinine clearance) in older adults.
 Decisions on management of older adults should not be based
solely on chronologic age but should be patient-centered, with
consideration given to general health, functional and cognitive
status, comorbidities, life expectancy, and patient preferences
REF: Circulation. 2011;123:000-000.
NSTEMI – Case
55yo ♀
85yo ♀
Presents with SOB, CP
no prior cardiac hx
BP: 130/89 mmHg
Weight: 238 lbs
EKG: Sinus 95, TWI laterally
Creat 1.0, HCT 33%
BP: 165/75 mmHg
Weight: 108 lbs
EKG: Sinus 95, LVH, TWI laterally
Creat 1.0, HCT 33%
Comorbidities: HTN
GERD
Obesity
Smoking
Comorbidities: HTN
Prior stroke
HF NEF
OA
ASA, 2L O2 NC, Nitro, Beta Blocker
Troponin +
Older Adults: Conservative v. Invasive
I IIa IIb III
Older patients face increased early procedural risks
with revascularization relative to younger patients,
yet the overall benefits from invasive strategies are
equal to or perhaps greater in older adults.
REF: Anderson J. J Am Coll Cardiol 2007;50:652-726
Older Adults: Benefit of Invasive Care
(TACTICS TIMI 18)
Event Rate (%)
OR
Age Group
(n)
Cons.
Inv.
(Inv v. Cons)
≤55 y
(716)
4.8
5.0
1.07
56-65 y
(614)
9.1
7.6
0.82
66-75 y
(612)
10.3
7.8
0.73
≥75 y
(278)
21.6
10.8
0.44*
NNT = 67
NNT = 9
* P <0.016
0
0.5
Invasive Better
1
1.5
Conservative Better
DEATH or MI at 6 mo
Source: Bach AIM 2004; 141:186-195
2.0
NSTEMI – Case
55yo ♀
85yo ♀
IV heparin: 5000 U then 1000 U/hr
Cath Lab: LCX 95% hazy
IV Integrelin, Drug-eluting stent
Appropriate Heparin
Appropriate Integrilin
Excess Heparin (3000 U/ 600 U/hr)
Excess Integrelin
CrCl=98 ml/min
CrCl = 30 ml/min
Creatinine 1.0 mg/dl
Creatinine 1.0 mg/dl
Weight 238 lbs
Weight 108 lbs
*Based on Heparin 60 U/kg bolus and 12 U/kg infusion, cap 4000/1000
and Integrilin reduced infusion dose if CrCl <50ml/min
2011 UA/NSTEMI Guidelines : Special Population Section
I IIa IIb III
 Attention should be given to adjusting antiplatelet and anticoagulant doses based on
weight and renal function (eg. estimated
creatinine clearance) in older adults.
REF: Circulation. 2011;123:000-000.
Excess Antithrombotic Dosing
Avoidable Risk
70
64.5
% Excessive Dose
60
50
37 38.5
40
28.7
30
20
33.1
12.5 12.8
16.5
8.5
10
0
LMW Heparin
< 65 yrs
UF Heparin
65-75 yrs
GP IIb/IIIa
>75 yrs
REF: Alexander KA, JAMA 2005
NSTEMI – Case
55yo ♀
85yo ♀
Mortality = 0.8%
Bleeding = 6.5%
Mortality = 3.9%
Bleeding = 18.2%
Low Crusade Bleeding Risk
Very High Crusade Bleeding Risk
D/C home day 3
Major Bleed, transfusion, volume
overload, HFNEF, bouts of afib,
hemodynamic instability, Confusion,
↑ LOS
*Based on Heparin 60 U/kg bolus and 12 U/kg infusion, cap 4000/1000
and Integrilin reduced infusion dose if CrCl <50ml/min
CRUSADE Bleeding Score
HCT (%)
CrCl (mL/min)
DM
Female
Signs of CHF
PVD
Heart rate
SBP
REF: Subherwal S. The Crusade Bleeding Score. Circulation 2009;119: Epub
REF: Subherwal S. The Crusade Bleeding Score. Circulation 2009;119: Epub
Major Bleeding with Antithrombotic therapy
Unavoidable Risk
≥2 Antithrombotics (anti-platelet [aspirin or clopidogrel], anti-coagulant, or GP IIb/IIIa; n=50,969; c-index 0.72)
<2 Antithrombotics (anti-platelet, anti-coagulant, or GP IIb/IIIa; n=5,931; c-index 0.73)
REF: Subherwhal, Circ 2009;119: 1872-1882
Therapeutics in ACS Among
Patients >90 Years Old
Mortality
Major Bleeding
In-hospital Mortality by Number of Therapies
Optimal
20
% major bleeding**
30
25
% mortality
Major Bleeding by Number of Therapies
20
15
10
5
0
18
16
14
12
10
8
6
4
2
0
None
One
Two
Three Four
Five
Number of Recommended Therapies*
(p<0.001 for trend)
Age 75-89
Age 90 and older
None
One
Two
Three
Four
Number of Recommended Therapies*
(p<0.01 for trend)
(CABG Pts and contraindications excluded)
Five
Age 75-89
Age 90 and older
Even among oldest old – better outcomes with better adherence to
ACC/AHA Guidelines
(1) Acute Aspirin, (2) Acute Beta-blockers, (3) Acute Heparin, (4) GP
IIb/IIIa inhibitors with PCI, (5) Cardiac Catheterization <48 hours
- Skolnick et al, JACC 2007
ACUITY: Major Bleeding in PCI Cohort
Strategy Matters
P=0.00
1
P<0.001
% Major Bleeding Events
18%
16%
14%
Hep + GPI
Age <55
– NNT 38
P=0.010
10%
6%
4%
16.5
Biv alone
NNT to prevent one major bleed
12%
8%
Biv + GPI
P=0.007
P=0.033
Age >75P=0.001
– NNT 16
P=NS
6.7
6.6
P=0.006
12.3
6.1
5.5
5.7
4.2
4.3 4.2
3.0
2%
1.7
0%
<55
55-64
65-74
>=75
N=2052
N=2240
N=2121
N=1376
Patient Age
Excluding CABG-related bleeding
REF: Lopes JACC 2009
Quality of Care for Hospitalized Elders and PostDischarge Mortality
6,392 Vulnerable Elderly Patients identified a using VES-13 Survey
One year mortality based on adherence to Geriatric ACOVE Measures
ACOVE Quality of Care above Median =
18% reduction in 1 year death
Discharge Planning
Assess Nutrition
Assess Cognition
Assess Mobility
Mobility intervention
Delerium Management
Pressure Ulcer Management
REF: Aurora JAGS 2010;58: 1642-1648
Quality of Care for Hospitalized Elders and PostDischarge Mortality
6,392 Vulnerable Elderly Patients identified a using VES-13 Survey
One year mortality based on adherence to ACOVE Measures
ACOVE Quality of Care above
Median = 18% reduction in 1 year
death
REF: Aurora JAGS 2010;58: 1642-1648
MI – Discharge
55yo ♀
ASA, Plavix, BB, Statin
5 days returned to work
Follow up appointment 1 week
Enrolled in Cardiac Rehab
85yo ♀
ASA, Plavix, BB, ACEi, Statin
+
6 other medications
At home alone during the day
No follow up appointment
Sedentary, weak
Discharge: Take-off and Landing
• Successful Outpatient visit plan
– Early Follow up Appointment (Cardiology or Medicine)
– Successful communication
• Return to Independent Function
– Consider caregiver support, home safety
• Avoid Complications, Rehospitalization
– Medication Review, Education, Simplification
– Symptom Education
– Clear Contact Information
Cardiac Rehab and Survival In Older Cardiac
Patients
Cardiac Rehab Participation = 21%
>600,000 Medicare Beneficiaries (ICD-9: AMI, ACS, Stable CAD, CABG, PCI)
to 34% lower Mortality
70,040 Propensity Matched Pairs; Regression Modeling; Instrumental Variable Analysis
REF: Suaya JA et al, JACC 2009;54:25-33
2011 UA/NSTEMI Guidelines : Special Population Section
I IIa IIb III
 Consideration should be given to patient
and family preferences, quality-of-life issues,
end-of-life preferences, and sociocultural
differences in older patients with
UA/NSTEMI.
REF: Circulation. 2011;123:000-000.
“What are the most important goals from the
treatment of your heart disease?”
80
% Reporting in Top 3
70
N=626
60
50
40
30
Lengthen Life
Maintain Mental Ability
Maintain Independence
20
10
0
45-59
60-69
70-79
80+
Patient Age
REF: Alexander ACC Abstract
STEMI Reperfusion
REF: Bueno, EHJ 2010;54:25-33
Conclusions

Chronologic age ≠ biologic age

Treatment recommendations similar….

– Age 75 is cut point for altered paradigm of care
– Comorbidities, altered physiology, function alter risk/benefit
– Avoid errors of omission and commission
– Dosing and delivery matter…perhaps more
– Avoid hazards of hospitalization, transitions of care
Extending EBM to personalized care …
–
–
–
–
More representative trials
Best practice recommendations
Explicit discussions of patient goals for treatment
Transitions of Care, Goals of Care
Older Adult
Cardiologist
OUTCOMES
Corinth Canal: Isthmus 5 miles long between Greece and Peloponnesus
Future Directions
– Advance Science
• Adding Key data elements to large registry work
• Comorbidity: non-cardiac issues that alter cardiac management
• Physiology (Vascular Stiffness, HF NEF, Sinus node
dysfunction)
• Genetics (Telomere length, genetic aging)
– Advance “Best Practice” and systems research
• Drug Safety
• Care models, collaboration
• Transitions of care
– Broaden perspectives on goals of care
• Functional Status and recurrent procedures