1. Cardiac Intervention in the Elderly

2. Cardiac Interventions Coronary Artery Bypass Grafting (CABG) Percutaneous Transluminal Coronary Angioplasty (PTCA) ± stenting Valve surgery Radio-frequency Ablation Automatic Implantable Cardiac Defibrillators (AICDs)

3. Ischaemic Heart Disease Largest single cause of death in developed world Medical therapy CABG (Favaloro in 1969) PTCA (Gruentzig in 1977) Coronary stents (Sigwart in 1989)

4. CABG 600 000/year in the USA Many trials selective/unrepresentative: –Males under 65 years old –Pre- Aspirin/Beta-blocker/ACE-I/Statin era –Saphenous vein grafts only

5. CABG - Mortality Mortality (in-hospital)1.3% Predictors: »AGE »Co-morbidity »Pre-operative LV function »Surgical parameters »IABP requirement

6. CABG – Mortality NNECDSG SCORE Age + Gender LV Ejection Fraction Urgency of Surgery Previous CABG PVD, Diabetes, Renal Failure, COAD Body Habitus

7. NNECDSG score Mortality scoreCVA score Age 60-6923.5 Age 70-7935 Age  80 56 Renal dialysis42 Each point = 0.2 – 2 % rise in mortality

8. CABG – 30 day Mortality < 70 years> 70 years All CABG1.3 %3.9 % AVR + CABG3 %7.3 % MVR + CABG13 %12.5 % Emergency surgery 18.4 %32 %

9. CABG – Neurological risks CVA 3% Prior neurological disease IABP use Diabetes Hypertension Unstable angina Increased age Prox. aortic atheroma Drop in intellect3% Excess alcohol consumption Arrhythmias Hypertension Previous CABG Peripheral vascular disease Congestive heart failure Increased age

10. CABG – Morbidity Renal failure 8 % of all patients 1 % require dialysis (1.2 % of > 70 years) Major predictor of mortality 18 % of patients die 66% of dialysis patients die Risk factors Advanced age, CCF, re-do surgery, diabetes

11. CABG – Morbidity Mediastinitis Deep sternal wound infection – 1% to 4% of patients – Mortality of 25% Predicted by: –Obesity –Re-do surgery –Use of both IMA’s at surgery –Diabetes mellitus

12. Survival after CABG CABG vs. Medical Rx Mortality: @ 5 years: 10.2 % (CABG) vs. 15.8 % (medical) @ 10 years: 26.4 % (CABG) vs. 30.5 % (medical) Greatest benefit: –Left main stem or equivalent –Proximal LAD involvement

13. Survival after CABG Proximal LAD disease Relative risk reduction for CABG compared with medical treatment – 42 % @ 5 years – 22 % @ 10 years Benefit increased if LV impaired

14. PTCA  stent Most trials performed before: Stents Clopidogrel IIb/IIIa platelet inhibitors 447 000 procedures/year in USA (1997)

15. PTCA  stent Procedural success now 99.5% (76% in 1986) Mortality  0.91% (UK values)  0 % (stents)  1.2% (stents in diabetic patients) Early repeat procedure (<7 months after 1 st )  23.3 % with POBA  13.5 % with stents

16. PTCA (no stent) Mortality/morbidity 10 year follow-up: – Q-wave MI 3.9% – non Q-wave MI 11.3% – Death 23.1 % – CABG 32.7 % – Repeat procedure 38% – Recurrent angina 56.3 % Risk factors: Extent of disease Diabetes Hypertension Previous MI Male Age >70 (mortality)

17. PTCA + stenting Mortality/morbidity Follow – up data is over shorter period Most data is pre - ticlopidine/clopidogrel Death rate @ 1 year 0.7 – 1.2% Target lesion re-intervention 15% (1yr) Cardiac event free survival 78% (1yr) Outcomes similar for single vs. multivessel

18. PTCA + stenting Mortality/morbidity Influence of ticlopidine MACE level dropped from: – 24.1% to 9.0 % (in hospital) – 47% to 33% (2 years)

19. PTCA  stenting Influence of age Study from 1980 –1996 < 5070-79>80 In-hospital mortality0.28 %2.1 %3.45 % Q-wave MI1.6 %1.0 %2.54 % CABG4.94 %3.5 %2.7 % 5 year survival94 %76 %65 %

20. PTCA  stenting Influence of age < 70 years 1yr 5yrs  70 years 1yr 5yrs Non Q-wave MI1.3 %5.1 %1.2 %5.8 % Severe angina22.9 %39.2 %22.1 %37.2 % Repeat PTCA11.0 %22.9 %9.3 %18.6 %

21. CABG or PTCA? Data pre-stent / clopidogrel / IIb/IIIa inhibitors BARI trial:Lower mortality with CABG vs. PTCA –Diabetic patients do better with CABG –Non-diabetic patients – No difference QALY/activity/employment/costs equivalent at 5 years Recurrence of angina higher in PTCA –21% vs 15% @ 5 years

22. Valve surgery in > 80 yrs age High rate of co-morbidity &40-60% IHD  15-25% COAD &5-25% CVA  20-50% Hypertension Age > 80 years AVR MVR

23. Valve surgery in > 80 yrs age Risk score EF: 30-50% +2 EF <30% +5 Re-operation +2 Valve & CABG +2 Age > 80 years AVR MVR

24. Valve surgery in > 80 yrs age Appropriateness of surgery AVR for severe aortic stenosis +++ MVR for severe mitral regurgitation ++ AVR for moderate AS during CABG ++ MV repair for moderate MR at CABG + Balloon valvuloplasty for MS + MVR for moderate MR during CABG 0 AVR + MVR 0 Balloon valvuloplasty of aortic valve 0

25. Symtomatic Aortic Stenosis in the > 80 Year Old

26. Radio-frequency ablation Introduced in the 1980’s Treatment of choice in symptomatic SVT’s –AVNRT –AVRT (i.e. WPW) –Atrial flutter NO PROGNOSTIC ADVANTAGE

27. RFA Statistics Mortality0.3% Major complication3% Success85 – 100% (95%) Recurrence2 – 21%

28. RFA in the elderly Little data Most common procedure is AVJ (node) ablation for atrial fibrillation + PPM Age not a predictor of success/complication Structural heart disease Multiple accessory pathways Heart disease Low ejection fraction AVJ ablation Complications Death

29. AICD’s Undoubted prognostic benefit Procedural mortality 0.5 – 0.8 % Primary prevention Secondary prevention

30. AICD’s –Primary Prevention Previous MI and all of the following: –Non-sustained VT on Holter (24 hour ECG) –Inducible VT at EPS –LV dysfunction EF < 35% NYHA I – III Familial cardiac condition with risk of sudden death (long QT, HOCM etc.)

31. AICD’s – secondary prevention Patients who present, in the absence of a treatable cause, with: –Cardiac arrest due to VT or VF –Sustained VT causing syncope or significant haemodynamic compromise –Sustained VT without haemodynamic compromise + EF < 35% + NYHA I - III

32. Conclusions Age is a significant risk factor in most cardiac interventions, but does not preclude intervention Co-morbidity is a major factor in deciding appropriateness of intervention AVR is well worthwhile in isolated AS Treat the person, not the birth date!