management of acs in the elderly: focus on...
TRANSCRIPT
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HCMC Tamduc Conference 5-6 Oct 2019
Management of ACS
in the Elderly: focus on PCI
Adj Prof Koh Tian Hai
Senior Consultant, Dept of Cardiology
Senior Advisor
National Heart Centre, Singapore
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I have no conflict of interest to report with regards to this presentation.
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Age 94 yrs
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Silver Tsunami
Source: Straits Times
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Life Expectancy at Birth S’pore & Demographic changes with time
Spore Govt Statistics
Spore Govt Statistics
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Spore Myocard Infarct Registry(SMIR) STEMI & NSTEMI incidence rates: 2008-2017
Accessed 29sep2019: SMIR-NDRO Spore
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How to manage these Elderly patients
when they develop ACS?
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Approach to ACS
Low
Risk
• Ischaemia guided strategy
High
Risk
• Early Invasive Management
RISK SCORE ASSESSMENT
DAPT LMWH
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TACTICS-TIMI 18
CP Cannon et al. NEJM 2001; 344: 1879-87
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Risk Stratification: TIMI Risk Score
EA Amsterdam et al. JACC 2014; 64: e139-228
• Age>65 • >3 risk factors for CAD • Prior coro stenosis >50% • ST deviation on ECG • >2 anginal events prior 24h • Use of aspirin prior 7 days • Elevated cardiac biomarkers
E Antman et al JAMA 2000; 284: 835-42
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GRACE Score
KA Eagle et al. JAMA 2004; 291: 2727-33
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ACS-TIMI Risk Score Stratification
CP Cannon et al. NEJM 2001; 344: 1879-87
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The Elderly Subgroup-Why Special?
• Elderly >75yr old
• Underrecognised as atypical presentations
• Underrepresented in clinical trials vs community cases
• Few randomised ACS trials specific to elderly
• Co-morbidities and risks increased
• Confounding Socio-economic-psychological issues
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Atypical Clinical Presentations of ACS in Elderly
• Classical chest pain not as common
• Dyspnoea+, hypoxia
• Diaphoresis, Nausea & Vomiting
• Pre-Syncope
• Fatigue
• Altered mental state
• Tachycardia, hypotension, anaemia,
• Common to have Type II MI : infections, perioperatively
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ACS Case illustration: 80yr male ACS with pneumonia
Pre PCI Pre PCI
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Pre PCI Pre PCI
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Pre PCI- failed IVUS Pre PCI RCA
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1.5 burr to OLCX RA 1.5 burr to LM-LAD
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Post POBA to both LM-LAD & LCX
Post OLCX burr
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Culotte LM into OLCX DES to LM-LAD
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Final Kissing inflations
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Angio final LM-LAD-LCX
Rao cranial Final-spider
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RCA
RCA post stenting final RCA rotablation
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NHCS: Yearly Trend of NSTEMI-PCI 2013-2017 age > 80yr
24 22 28 42 40
321 276
337 388
351
345
298
365
430
391
0
50
100
150
200
250
300
350
400
450
500
0
100
200
300
400
500
600
2013 2014 2015 2016 2017
TOTA
L N
UM
BER
OF
CA
SES
NU
MB
ER O
F C
ASE
S
YEAR OF PROCEDURE
Yearly Trend of NSTEMI PCI
Age >=80 Age <80 Total
Source: Singapore Cardiac DataBank
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NHCS Risk Factors : Age Comparison
89.1%
56.4%
7.1%
76.3%
5.8% 12.2%
100
73.2%
47.8%
29.0%
71.5%
13.7% 6.9%
88
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Hypertension DiabetesMellitus
Current Smoker Dyslipidaemia Premature CAD AtrialFibrillation
MedianCreatinine
Value, umol/L
Risk Factors
Age>=80 Age<80
P-value<0.001 P-value=0.039 P-value<0.001 P-value=0.208 P-value=0.005 P-value=0.017 P-value=0.001
Source: Singapore Cardiac DataBank
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NHCS Number of Vessels Diseased
23.1%
11.5%
25.6%
62.8%
12.2%
25.4%
31.2%
43.3%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Left Main SVD DVD TVD
Number of Vessels Diseased
Age>=80 Age<80
A case can have combinations of the number of vessels diseased(e.g. LM+DVD, LM+ TVD etc)
P-value<0.001 P-value<0.001 P-value=0.150 P-value<0.001
Source: Singapore Cardiac DataBank
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NHCS Number of Vessels Diseased
23.1%
11.5%
25.6%
62.8%
12.2%
25.4%
31.2%
43.3%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Left Main SVD DVD TVD
Number of Vessels Diseased
Age>=80 Age<80
A case can have combinations of the number of vessels diseased(e.g. LM+DVD, LM+ TVD etc)
P-value<0.001 P-value<0.001 P-value=0.150 P-value<0.001
Source: Singapore Cardiac DataBank
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NHCS Rotablator Use
18 11.5%
138 88.5%
Age>=80 (n=156)
Yes No
75 4.5%
1598 95.5%
Age<80 (n=1673)
Yes No
P-value<0.001
Source: Singapore Cardiac DataBank
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NHCS Procedural Success
154 98.7%
2 1.3%
Age>=80 (n=156)
Success Failed
1673 99.0%
17 1.0%
Age<80 (n=1673)
Success Failed
P-value=0.754
Source: Singapore Cardiac DataBank
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Age>=80 Age<80 P-Value
In-hospital Mortality(%) 7.1% 3.2% 0.014
30-day Mortality(%) 7.7% 3.7% 0.016
One-year Mortality(%) 20.5% 7.8% <0.001
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%%
. OF
NST
EMI P
CI C
ASE
S
NSTEMI PCI Mortality
NHCS NSTEMI Mortality after PCI
Source: Singapore Cardiac DataBank
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Invasive vs Conservative Strategy in >80yr NSTEMI-ACS: After 80 Study
Open label Randomised trial >80yrs 4187 pt screened 457 pts randomised1:1 Median fu of 1.5 yrs 1 end pt: all death, MI, stroke,Urgent revascularisation.
N Tegn et al. Lancet 2016; 387: 1057-65
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Co-morbidities:After 80 study
N Tegn et al. Lancet 2016; 387: 1057-65
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After 80: Primary Endpoint Invasive vs Conservative Strategy
All Death, MI, Stroke & revascularisation
N Tegn et al. Lancet 2016; 387: 1057-65
1 end point: I=40.6%; C=61.4% P=0.0001 Major bleeding: I=1.7%; C=1.8% P=ns
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VERDICT
KF Kofoed et al. CIRC 2018; 138: 2741-50
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VERDICT: Combined Pri End Point Early Invasive vs Standard
KF Kofoed et al. CIRC 2018; 138: 2741-50
Hazard Ratios for the subgroups Primary End Point:p=ns
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Elderly have an increased bleeding risk
• Oral PPI rx.
• Dose of anticoagulants should be body weight and eGFR adjusted.
• Prasugrel dose reduced to 5mg daily if wt <70kg or age>70yrs.
• Transradial route preferred for PCI access.
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Radial vs Femoral Access in ACS-PCI: Meta-analysis
M Valgimigli et al. Lancet 2015; 385: 2465-76
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Further issues that occurs more commonly with ACS-PCI in Elderly
• Complex lesions, Multivessel Disease
• Calcified
• Left Main
• Increased risk of renal injury
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EXCEL Trial: ACS in LM PCI
S Doucet et al. Am Hrt J 2019; 214: 9-17
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EXCEL Results: SIHD cf with ACS in LM-PCI
S Doucet et al. Am Hrt J 2019; 214: 9-17
Acuity of Presentation does not influence outcome
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Increased CKD in the elderly
• Increased bleeding risk
• Increased risk of adverse events
• Gradient of mortality risk with increasing CKD severity
• High residual platelet reactivity, – increased stent thrombosis
• Overdosing of medications
• eGFR by CG formula (vs MDRD) preferred for anticoagulant adjustment.
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2016 ACC/AHA guidelines
:
DAPT Duration
in ACS
GL Levine et al. Circ 2016: 134: e123-55
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Further Considerations in Rx Elderly ACS
• Polypharmacy
• Multiple Co-morbidities
• Frailty
• Functional disabilities
• Reduced Cognition
• Readmissions for noncardiac disease
• Care Coordination/care giver burden
• Financial/insurance considerations
• End-of-life Choices/shared decisions
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Review of points discussed
• Changing population demographics
• Age related variation in clinical presentation of ACS
• Comorbidities associated with the elderly
• How pci treatment may differ for the aged
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Singapore Case Fatality Rates in STEMI & NSTEMI: 2008-2017
AMI : STEMI vs NSTEMI
Accessed 29sep2019: SMIR-NDRO Spore
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Take Home Messages : elderly with ACS-PCI
• Invasive therapy is better than conservative Medical Management for high risk ACS. Early invasive better than routine invasive in high risk subset ACS: Grace Score >140.
– ? Benefit of invasive rx in Age >90yr.
• Expect more complex coronary anatomy:
• Multivessel & Left Main, Calcified
• Increased bleeding risks:
– radial is better than femoral approach
– duration/choice of DAPT
– Inreased AF incidence & use of antithrombotics with DAPT
• Increased risk of renal injury: age, CKD, complex anatomy
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• Renal dysfunction, and frequent multiple co-morbidities
necessitate medication dosage adjustments for safety.
• Fragility and other neurological/care issues: delirium, dementia. Tailored individualised management strategies required, due to varying psychosocial needs.
• More trials with specific focus on elderly are urgently needed
because of an increasing elderly population.
• Invasive management still underutilised despite increased absolute benefit
Take Home Messages : elderly with ACS-PCI
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National Heart Centre, Singapore
THANK YOU
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After 80: Influence of Age on Primary Endpoint
uncertain benefit if age >90yr
N Tegn et al. Lancet 2016; 387: 1057-65
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REDUCE Trial: 3 vs 12 mth DAPT in ACS with COMBO stent: final 2 yr followup
Results
G de Luca et al. EuroIntv 2019; online
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REDUCE Trial
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DAPT 6 vs 12 mths in
Elderly pt with 2nd
Geneneration DES
SY Lee et al. JACCIntv 2018; 11:435-43
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SY Lee et al. JACCIntv 2018; 11:435-43
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SY Lee et al. JACCIntv 2018; 11:435-43
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NOAC & P2Y12 inhibitor vs Vit K+DAPT:
Pooled Outcomes: Safety & Efficacy
P Vranckx et al. Lancet 2019
online sep 3
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Pooled Trials of NOAC+P2Y12
Inhibition vs Vit K +DAPT
P Vranckx et al. Lancet 2019
online sep 3
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