Transcript Geriatric Cardiology: An American Growth Industry

Geriatric Cardiology: A
Global Growth Industry
Joseph S. Alpert, MD
Department of Medicine
University of Arizona Health Sciences
Center, Tucson, Arizona
Editor-in-Chief, American Journal of
Medicine
Potential Conflicts of Interest:
1. No major conflicts of interest, i.e.,
all honoraria <$5,000;
2. Consultations currently or
previously performed:
Sanofi-Aventis, Merck, Bristol-MyersSquibb, Pfizer, Astra-Zeneca,
McNeill, Organon, Berlex, Novartis,
Ciba-Geigy, Roche, Exeter CME.
DEMOGRAPHICS
Population Projections in the U.S.:
2000-2050
Population in millions
50
40
Women >65
Men > 65
Women > 85
Men > 85
30
20
10
0
2000
2010
2020
2030
2040
2050
Hospital Mortality for
Cardiovascular Causes
Acute MI
Arrhythmias
Heart failure
Cerebrovascular disease
Total deaths
(in thousands)
78
17
42
65
Age > 65
68 (87.2%)
12 (70.6%)
37 (88.1%)
49 (75.4%)
Source: National Hospital Discharge Survey, 1998.
EFFECTS OF AGING ON THE
CARDIOVASCULAR SYSTEM
Principal Effects of Aging on
Cardiovascular Structure and Function
Increased vascular + myocardial
stiffness
 Decreased -adrenergic and
baroreceptor responsiveness
 Impaired sinus node function
 Impaired endothelial function

Net effect - Large reduction in CV reserve
CV Changes: Max Exercise - Ages
20 and 80 Years
Oxygen consumption
Reduced ~ 50%
AV oxygen difference
Reduced ~ 25%
Cardiac output
Reduced ~ 25%
Heart rate
Reduced ~ 25%
LV stroke volume
Reduced ~ 15% to 25%
LV end diastolic volume
No change or small
decrease
LV end systolic volume
Increased ~ 150%
LV ejection fraction
Reduced ~ 15%
Age Changes in Systolic and
Diastolic BP
Source: J Gerontol Med Sci 1997;52:M177-83
Conduction System




Increased elastic tissue, collagen and fat,
especially in the SA node with marked
reduction in SA node pacemaker cells
Calcification of cardiac skeleton
Slowed conduction throughout the heart
Hypertension, CAD, and amyloid
infiltration amplify conduction
abnormalities
Arrhythmias




Marked increase in frequency of supraventricular and ventricular ectopic beats
Short runs of SVT occur in 1/3 of healthy
older subjects on Holter studies
Ventricular couplets occur in ~11% and
short runs of ventricular tachycardia
occur in ~4% of normal persons > 60 yr
In the absence of heart disease, none of
these arrhythmias are associated with an
adverse prognosis
Source: Am J Cardiol 1992:70:748-51
Prevalence of Nonsustained SVT
during Maximal Exercise
Source: Am J Cardiol 1995;75:788-92
Clinical Implications




Increased systolic BP and pulse pressure
Increased prevalence of atrial fibrillation,
heart failure, especially heart failure with
preserved LV function
Increased prevalence of bradyarrhythmias
and “sick sinus syndrome”
Worse prognosis associated with all CV
diseases
Disease Presentation


Atypical symptomatology
- Chest pain less frequent
- Exertional dyspnea or fatigue common
- ‘Gastrointestinal’ symptoms common
- Confusion, dizziness, other CNS sx’s
Non-diagnostic ECG due to IVCD, LVH,
paced rhythm, electrolyte abnormalities
CORONARY HEART DISEASE
IN THE ELDERLY
Prevalence of AHSD by Age and Sex in
the U.S. from 1988-94
20%
15%
Male
10%
Female
5%
0%
25-44
45-54
55-64 65-74
75+
Age, years
Source: National Health and Nutrition Examination Survey
Prognosis after AMI by Age
Source: Circulation 1996;94:1826-33
Vaccarino et al Ann of Int Med 2001; 134: 173-181. Solid lines are men; dotted lines
are women.
Risk Stratification Post-MI
The Cooperative Cardiovascular Project risk score (age
> 65 years), GISSI, GUSTO
FACTORS INCREASING MORTALITY:

Older age groups - # 1

Urinary incontinence; decreased functionality;
peripheral vascular disease; low body mass index;
renal insufficiency; decreased LV function
Krumholz et al JACC 2001; 38: 453. Marchioli et al Eur Heart J 2001; 22: 2085. Califf et al
Circulation 2000; 101: 2231.
Thrombolysis vs. Angioplasty in
Older Patients
Death
100
Death, re-MI, Stroke
Overall Survival, (%)
100
RR 5.2
90
90
80
p = 0.04
80
p = 0.003
70
60
70
50
PCI, N = 46
SK, N = 41
0
Survival Free of
Reinfarction or Stroke, (%)
0
1
2
0
0
Year
De Boer et al., J Am Coll Cardiol 39:1723-8,
2002
1
Year
2
PCI vs. Lysis Meta-Analysis
23 Trials, 7739 Patients
Death
10
8
Re-MI
% of Pts.
9
p = 0.002
6
4
4
2
2
0
0
Lysis
% of Pts.
10
PCI
% of Pts.
p < 0.001
p = 0.0004
8
8
7
6
10
Stroke
7
6
4
3
Lysis
PCI
Weaver et al., JAMA 278:2093,1997;
Keeley et al., Lancet 361:13-20,
2003
2
0
2
1
Lysis
PCI
Primary Angioplasty for AMI in the
Elderly: Pooled Analysis from 3 Trials
20%
15%
10%
P=0.02
P=0.21
Angioplasty
Thrombolysis
5%
0%
< 70
> 70
Age, years
Source: J Intervent Cardiol 1998;10:4A-10A
GUSTO
V
Intracranial Hemorrhage
Treatment by Age Interaction
3
Percent
p = 0.033
rPA
rPA + Abciximab
OR 1.91
p = 0.065
2
2.1
2.1
OR 0.76
p = 0.26
1
0.5
0
1.1
0.4
0.4
Age < 75
Age > 75
GUSTO
V
The Age-Intracranial Hemorrhage
Interaction
HIGHER RISK
LOWER RISK
Source: Am Heart J 2001:142:37-42
Reasons Reperfusion Missed
94 Hospitals in 14 Countries, N =
1763
30% no reperfusion:
OR
Age  75
No CP
Prior CHF
Prior CABG
DM
2.4
3.2
2.9
2.3
1.5
Eagle et al., GRACE Registry, Lancet 359:373–
77, 2002
CARDIOVASCULAR DRUG
THERAPY IN THE ELDERLY
Drug Therapy in the Elderly:
General Considerations

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Decreased volume of distribution
Decreased renal and hepatic clearance
Altered drug pharmacodynamics
Increased comorbidity
Increased risk of drug interactions
Paucity of data from clinical trials
IN GENERAL, ELDERLY
PATIENTS DO WELL WITH
EVIDENCE-BASED MEDICAL
AND INTERVENTIONAL
THERAPY ALTHOUGH
MORBIDITY AND
MORTALITY ARE HIGHER
THAN IN YOUNGER
PATIENTS
Efficacy of Aspirin by Age: ISIS-2
25%
20%
Placebo
15%
Aspirin
10%
5%
0%
< 60
60-69
Age, years
70+
Source: Lancet 1988;II-349-60
Long-term Benefits of Aspirin
25%
20%
P < 0.00001
P < 0.00001
15%
Aspirin
10%
Control
5%
0%
< 65
65+
Age, years
Source: BMJ 1994;308:81-106
Clopidogrel in Non-ST-Elevation
Acute Coronary Syndromes: CURE
Age,
years
Relative
Lives
Placebo Clopidogrel Risk* Saved/ 1000
< 65
7.6%
5.4%
0.71
22
> 65
15.3%
13.3%
0.87
20
*Primary endpoint: CV death, nonfatal MI or CVA
Source: N Engl J Med 2001;345:494-502
Impact of Statins on Major Coronary
Events
Placebo
Active
Relative
Risk
Events
Prevented
4S
< 65
> 65
CARE
< 65
> 65
LIPID
< 65
> 65
26.4%
33.4%
18.1%
23.6%
0.66
0.66
83
98
25.6%
28.1%
21.1%
19.7%
0.81
0.68
45
84
13.4%
19.7%
10.4%
15.5%
0.77
0.79
30
42
VALVULAR HEART DISEASE
IN THE ELDERLY
Prevalence of AS in the Elderly
20%
15%
Men
Women
10%
5%
0%
White
Hispanic
Source: Aronow WS et al. Am J Cardiol 2001;87:1131-3
Prevalence of AI in the Elderly
40%
30%
Men
Women
20%
10%
0%
White
Hispanic
Source: Aronow WS et al. Am J Cardiol 2001;87:1131-3
AV Replacement: Age > 80
Actuarial survival following AVR in 71 octogenarians
100%
80%
60%
40%
20%
0%
30-days
1 year
5 years
10 years
Source: Circulation 1989;80(suppl I):I-49-56
Conclusions



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There is rapid global growth in the number
of elderly patients with CV disease
Mortality from CV disease is high in elderly
patients
Evidence-based therapy is highly effective in
elderly patients
Careful selection and tailoring of such
therapies is mandatory for elderly patients
with CV disease