Karen P. Alexander

Acute Coronary Care in the Elderly, Part I Non–ST-Segment–Elevation Acute Coronary Syndromes: A Scientific Statement for Healthcare Professionals From the American Heart Association Council on Clinical Cardiology: In Collaboration With the Society of Geriatric Cardiology

Background— Age is an important determinant of outcomes for patients with acute coronary syndromes (ACS); however, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients with ACS who would stand to benefit. Reasons include limited trial data to guide the care of older adults and uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age or complex health status. Methods and Results— This 2-part American Heart Association scientific statement summarizes evidence on patient heterogeneity, clinical presentation, and treatment of non–ST-elevation ACS in relation to age (<65, 65 to 74, 75 to 84, and ≥85 years). In addition, we review methodological issues that influence the acquisition and application of evidence to the elderly patients treated in community practice. A writing group combining international cardiovascular and geriatric perspectives convened to summarize available data from trials (5 combined Virtual Coordinating Center for Global Collaborative Cardiovascular Research [VIGOUR] trials) and 3 registries (Global Registry of Acute Coronary Events, National Registry of Myocardial Infarction, and the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines national quality improvement initiative [CRUSADE]) to provide a conceptual framework for future work in the care of the elderly with acute cardiac disease. Treatment for non–ST-segment–elevation ACS (Part I) and ST-segment–elevation myocardial infarction (Part II) are reviewed. In addition, ethical considerations pertaining to acute care and secondary prevention are considered (Part II). The primary goal is to identify the areas in which sufficient evidence is available to guide practice, as well as to determine areas that warrant further study. Although treatment-related benefits should rise in an elderly population with high disease risk, data to assess these benefits are limited, outcomes of importance vary, and heterogeneity among the elderly increases treatment-related risks. Although a uniform approach to care in the oldest of the old is unlikely, understanding the major contributors to benefits and risks from treatment will advance the ability to apply guideline-based care in this subset of patients. Conclusions— Although a few recent trials have described treatment effects in older patients, others continue to exclude patients on the basis of age. Going forward, prospective trials should enroll elderly subjects proportionate to their prevalence among the treated population to define risk and benefit. Findings from age subgroup analyses should be reported in a consistent manner across trials, including absolute and relative risks for efficacy and safety. Outcomes of particular relevance to the elderly, such as quality of life, physical function, and independence, should also be considered. Creatinine clearance should be calculated for every elderly patient to enable appropriate dosing. In addition, physicians need an understanding of conditions unique to older patients (eg, frailty, cognitive impairment) that influence treatment goals and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed in the health context of the elderly patient with ACS.

Baseline Risk of Major Bleeding in Non–ST-Segment–Elevation Myocardial Infarction The CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) Bleeding Score

Treatment of non–ST-segment elevation myocardial infarction (NSTEMI) has traditionally focused on preventing or minimizing ischemic complications with potent antithrombotic medications and catheter-based interventions.1–3 Yet these reductions in recurrent ischemic events have come at the cost of increased major bleeding,4–7 which is itself associated with worse clinical outcomes.7–13 Bleeding complications have received attention recently, in part because newer antithrombotic agents for NSTEMI have unique ischemia and bleeding profiles. Some agents demonstrate low rates of major bleeding with similar efficacy,5,14 while others demonstrate higher rates of major bleeding with superior efficacy.15 Given the importance of safety and efficacy,12 the recent American College of Cardiology (ACC)/American Heart Association (AHA) practice guidelines placed renewed emphasis on risk stratification to guide treatment for NSTEMI.3 While tools for ischemic risk stratification are well described (i.e., TIMI, PURSUIT, and GRACE risk scores),16–18 bleeding risk stratification is more limited. The few bleeding risk stratification models in existence include treatments known to influence bleeding or are derived from subgroups or trial populations not representative of those at greatest risk.10,13,19 Consequently, better estimation of baseline risk of bleeding in NSTEMI patients is needed to facilitate optimal treatment selection. Using data from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) Quality Improvement Initiative, we developed and validated a scoring system to estimate baseline risk of in-hospital major bleeding in patients with NSTEMI. The CRUSADE bleeding score provides a tool that equips clinicians with the means to consider safety outcomes when making treatment decisions for patients with NSTEMI.Background— Treatments for non–ST-segment–elevation myocardial infarction (NSTEMI) reduce ischemic events but increase bleeding. Baseline prediction of bleeding risk can complement ischemic risk prediction for optimization of NSTEMI care; however, existing models are not well suited for this purpose. Methods and Results— We developed (n=71 277) and validated (n=17 857) a model that identifies 8 independent baseline predictors of in-hospital major bleeding among community-treated NSTEMI patients enrolled in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) Quality Improvement Initiative. Model performance was tested by c statistics in the derivation and validation cohorts and according to postadmission treatment (ie, invasive and antithrombotic therapy). The CRUSADE bleeding score (range 1 to 100 points) was created by assignment of weighted integers that corresponded to the coefficient of each variable. The rate of major bleeding increased by bleeding risk score quintiles: 3.1% for those at very low risk (score ≤20); 5.5% for those at low risk (score 21–30); 8.6% for those at moderate risk (score 31–40); 11.9% for those at high risk (score 41–50); and 19.5% for those at very high risk (score >50; Ptrend <0.001). The c statistics for the major bleeding model (derivation=0.72 and validation=0.71) and risk score (derivation=0.71 and validation=0.70) were similar. The c statistics for the model among treatment subgroups were as follows: ≥2 antithrombotics=0.72; <2 antithrombotics=0.73; invasive approach=0.73; conservative approach=0.68. Conclusions— The CRUSADE bleeding score quantifies risk for in-hospital major bleeding across all postadmission treatments, which enhances baseline risk assessment for NSTEMI care.

2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement.

Robert A. Harrington, MD, FACC, Chair Deepak L. Bhatt, MD, MPH, FACC, Vice Chair Victor A. Ferrari, MD, FACC John D. Fisher, MD, FACC Mario J. Garcia, MD, FACC Timothy J. Gardner, MD, FACC Federico Gentile, MD, FACC Michael F. Gilson, MD, FACC Adrian F. Hernandez, MD, FACC Alice K. Jacobs

Outcomes of cardiac surgery in patients age ≥80 years: results from the National Cardiovascular Network☆

OBJECTIVES The purpose of this study was to evaluate characteristics and outcomes of patients age > or =80 undergoing cardiac surgery. BACKGROUND Prior single-institution series have found high mortality rates in octogenarians after cardiac surgery. However, the major preoperative risk factors in this age group have not been identified. In addition, the additive risks in the elderly of valve replacement surgery at the time of bypass are unknown. METHODS We report in-hospital morbidity and mortality in 67,764 patients (4,743 octogenarians) undergoing cardiac surgery at 22 centers in the National Cardiovascular Network. We examine the predictors of in-hospital mortality in octogenarians compared with those predictors in younger patients. RESULTS Octogenarians undergoing cardiac surgery had fewer comorbid illnesses but higher disease severity and surgical urgency than younger patients. Octogenarians had significantly higher in-hospital mortality after cardiac surgery than younger patients: coronary artery bypass grafting (CABG) only (8.1% vs. 3.0%), CABG/aortic valve (10.1% vs. 7.9%), CABG/mitral valve (19.6% vs. 12.2%). In addition, they had twice the incidence of postoperative stroke and renal failure. The preoperative clinical factors predicting CABG mortality in the very elderly were quite similar to those for younger patients with age, emergency surgery and prior CABG being the powerful predictors of outcome in both age categories. Of note, elderly patients without significant comorbidity had in-hospital mortality rates of 4.2% after CABG, 7% after CABG with aortic valve replacement (CABG/AVR), and 18.2% after CABG with mitral valve replacement (CABG/MVR). CONCLUSIONS Risks for octogenarians undergoing cardiac surgery are less than previously reported, especially for CABG only or CABG/AVR. In selected octogenarians without significant comorbidity, mortality approaches that seen in younger patients.

Gait Speed as an Incremental Predictor of Mortality and Major Morbidity in Elderly Patients Undergoing Cardiac Surgery

OBJECTIVES The purpose of this study was to test the value of gait speed, a clinical marker for frailty, to improve the prediction of mortality and major morbidity in elderly patients undergoing cardiac surgery. BACKGROUND It is increasingly difficult to predict the elderly patients risk posed by cardiac surgery because existing risk assessment tools are incomplete. METHODS A multicenter prospective cohort of elderly patients undergoing cardiac surgery was assembled at 4 tertiary care hospitals between 2008 and 2009. Patients were eligible if they were 70 years of age or older and were scheduled for coronary artery bypass and/or valve replacement or repair. The primary predictor was slow gait speed, defined as a time taken to walk 5 m of ≥ 6 s. The primary end point was a composite of in-hospital post-operative mortality or major morbidity. RESULTS The cohort consisted of 131 patients with a mean age of 75.8 ± 4.4 years; 34% were female patients. Sixty patients (46%) were classified as slow walkers before cardiac surgery. Slow walkers were more likely to be female (43% vs. 25%, p = 0.03) and diabetic (50% vs. 28%, p = 0.01). Thirty patients (23%) experienced the primary composite end point of mortality or major morbidity after cardiac surgery. Slow gait speed was an independent predictor of the composite end point after adjusting for the Society of Thoracic Surgeons risk score (odds ratio: 3.05; 95% confidence interval: 1.23 to 7.54). CONCLUSIONS Gait speed is a simple and effective test that may identify a subset of vulnerable elderly patients at incrementally higher risk of mortality and major morbidity after cardiac surgery.

Acute Coronary Care in the Elderly, Part II

Background— Age is an important determinant of outcomes for patients with acute coronary syndromes. However, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients who would stand to benefit. Limited trial data are available to guide care of older adults, which results in uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age and complex health status. Methods and Results— Part II of this American Heart Association scientific statement summarizes evidence on presentation and treatment of ST-segment–elevation myocardial infarction in relation to age (<65, 65 to 74, 75 to 84, and ≥85 years). The purpose of this statement is to identify areas in which the evidence is sufficient to guide practice in the elderly and to highlight areas that warrant further study. Treatment-related benefits should rise in an elderly population, yet data to confirm these benefits are limited, and the heterogeneity of older populations increases treatment-associated risks. Elderly patients with ST-segment–elevation myocardial infarction more often have relative and absolute contraindications to reperfusion, so eligibility for reperfusion declines with age, and yet elderly patients are less likely to receive reperfusion even if eligible. Data support a benefit from reperfusion in elderly subgroups up to age 85 years. The selection of reperfusion strategy is determined more by availability, time from presentation, shock, and comorbidity than by age. Additional data are needed on selection and dosing of adjunctive therapies and on complications in the elderly. A “one-size-fits-all” approach to care in the oldest old is not feasible, and ethical issues will remain even in the presence of adequate evidence. Nevertheless, if the contributors to treatment benefits and risks are understood, guideline-recommended care may be applied in a patient-centered manner in the oldest subset of patients. Conclusions— Few trials have adequately described treatment effects in older patients with ST-segment–elevation myocardial infarction. In the future, absolute and relative risks for efficacy and safety in age subgroups should be reported, and trials should make efforts to enroll the elderly in proportion to their prevalence among the treated population. Outcomes of particular relevance to the older adult, such as quality of life, physical function, and independence, should also be evaluated, and geriatric conditions unique to this age group, such as frailty and cognitive impairment, should be considered for their influence on care and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed within the health context of the elderly patient.

Frailty assessment in the cardiovascular care of older adults

Due to the aging and increasingly complex nature of our patients, frailty has become a high-priority theme in cardiovascular medicine. Despite the recognition of frailty as a pivotal element in the evaluation of older adults with cardiovascular disease (CVD), there has yet to be a road map to facilitate its adoption in routine clinical practice. Thus, we sought to synthesize the existing body of evidence and offer a perspective on how to integrate frailty into clinical practice. Frailty is a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors. Upward of 20 frailty assessment tools have been developed, with most tools revolving around the core phenotypic domains of frailty-slow walking speed, weakness, inactivity, exhaustion, and shrinking-as measured by physical performance tests and questionnaires. The prevalence of frailty ranges from 10% to 60%, depending on the CVD burden, as well as the tool and cutoff chosen to define frailty. Epidemiological studies have consistently demonstrated that frailty carries a relative risk of >2 for mortality and morbidity across a spectrum of stable CVD, acute coronary syndromes, heart failure, and surgical and transcatheter interventions. Frailty contributes valuable prognostic insights incremental to existing risk models and assists clinicians in defining optimal care pathways for their patients. Interventions designed to improve outcomes in frail elders with CVD such as multidisciplinary cardiac rehabilitation are being actively tested. Ultimately, frailty should not be viewed as a reason to withhold care but rather as a means of delivering it in a more patient-centered fashion.

Role of Frailty in Patients With Cardiovascular Disease

Frailty is a geriatric syndrome of increased vulnerability to stressors that has been implicated as a causative and prognostic factor in patients with cardiovascular disease (CVD). The American Heart Association and the Society of Geriatric Cardiology have called for a better understanding of frailty as it pertains to cardiac care in the elderly. The aim of this study was to systematically review studies of frailty in patients with CVD. A search was conducted of Ovid MEDLINE, EMBASE, the Cochrane Database, and unpublished sources. Inclusion criteria were an assessment of frailty using systematically defined criteria and a study population with prevalent or incident CVD. Nine studies were included, encompassing 54,250 elderly patients with a mean weighted follow-up of 6.2 years. In community-dwelling elders, CVD was associated with an odds ratio (OR) of 2.7 to 4.1 for prevalent frailty and an OR of 1.5 for incident frailty in those who were not frail at baseline. Gait velocity (a measure of frailty) was associated with an OR of 1.6 for incident CVD. In elderly patients with documented severe coronary artery disease or heart failure, the prevalence of frailty was 50% to 54%, and this was associated with an OR of 1.6 to 4.0 for all-cause mortality after adjusting for potential confounders. In conclusion, there exists a relation between frailty and CVD; frailty may lead to CVD, just as CVD may lead to frailty. The presence of frailty confers an incremental increase in mortality. The role of frailty assessment in clinical practice may be to refine estimates of cardiovascular risk, which tend to be less accurate in the heterogenous elderly patient population.

Identifying frailty in hospitalized older adults with significant coronary artery disease

OBJECTIVES: To characterize physiological variation in hospitalized older adults with severe coronary artery disease (CAD) and evaluate the prevalence of frailty in this sample, to determine whether single‐item performance measures are good indicators of multidimensional frailty, and to estimate the association between frailty and 6‐month mortality.

Use of evidence-based therapies in short-term outcomes of ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction in patients with chronic kidney disease: a report from the National Cardiovascular Data Acute Coronary Treatment and Intervention Outcomes Network registry.

Background Chronic kidney disease (CKD) is a risk factor for myocardial infarction (MI) and death. Our goal was to characterize the association between CKD severity and short-term outcomes and the use of in-hospital evidence-based therapies among patients with STEMI and NSTEMI.Background— Chronic kidney disease (CKD) is a risk factor for myocardial infarction (MI) and death. Our goal was to characterize the association between CKD severity and short-term outcomes and the use of in-hospital evidence-based therapies among patients with ST-segment elevation MI (STEMI) and non–ST-segment elevation MI (NSTEMI). Methods and Results— The study sample was drawn from the Acute Coronary Treatment and Intervention Outcomes Network registry, a nationwide sample of STEMI (n=19 029) and NSTEMI (n=30 462) patients. Estimated glomerular filtration rate was calculated with the Modification of Diet in Renal Disease equation in relation to use of immediate (first 24 hours) therapies and early (first 48 hours) cardiac catheterization as well as in-hospital major bleeding events and death. Overall, 30.5% and 42.9% of patients with STEMI and NSTEMI, respectively, had CKD. Regardless of MI type, patients with progressively more severe CKD had higher rates of death. For STEMI, the odds ratio for stage 3a, 3b, 4, and 5 CKD compared with patients with no CKD was 2.49, 3.72, 4.82, and 7.97, respectively (Ptrend<0.0001). For NSTEMI, the analogous odds ratios were 1.81, 2.41, 3.50, and 4.09 (P for trend <0.0001). In addition, patients with progressively more severe CKD were less likely to receive immediate evidence-based therapies including aspirin, &bgr;-blockers, or clopidogrel, were less likely to undergo any reperfusion (STEMI) or revascularization (NSTEMI), and had higher rates of bleeding. Conclusions— Reports over the past decade have highlighted the importance of CKD among patients with MI. Data from this contemporary cohort suggest that patients with CKD still receive fewer evidence-based therapies and have substantially higher mortality rates.