Risk Stratification in Elderly Coronary Artery Disease Patients: Can We Predict Which Seniors Benefit Most from Revascularization Options?

Current Cardiovascular Risk Reports

Volumn 5, Issue 5, 2011, Pages 422-431

  McClurken, James B ^a   Rosenhek, Raphael ^b   Guy, T Sloane ^c   Forman, Daniel E ^d,e  

^a TEMPLE UNIVERSITY HOSPITAL   (United States)

^b MEDICAL UNIVERSITY OF VIENNA   (Austria)

^c Saint Joseph's Hospital of Atlanta   (United States)

^d BRIGHAM AND WOMEN S HOSPITAL   (United States)

^e New England Primate Research Center   (United States)

Author keywords

CABG; CAD; Comorbidity; Elderly; Frailty; PCI; Risk Scores

Indexed keywords

CLOPIDOGREL;

ANGIOCARDIOGRAPHY; CARDIOVASCULAR FUNCTION; CARDIOVASCULAR MORTALITY; CARDIOVASCULAR RISK; CLINICAL DECISION MAKING; COMORBIDITY; CORONARY ARTERY DISEASE; DISEASE ASSOCIATION; HEART MUSCLE REVASCULARIZATION; HUMAN; MORBIDITY; PRACTICE GUIDELINE; REVIEW; RISK ASSESSMENT; SYNTAX SCORE;

EID: 84873552624     PISSN: 19329520     EISSN: 19329563     Source Type: Journal    
DOI: 10.1007/s12170-011-0195-z     Document Type: Review

References (70)

1. Lakatta EG, Levy D. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part I: aging arteries: a "set up" for vascular disease. Circulation. 2003; 107(1): 139-46.
2. Lakatta EG, Levy D. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part II: the aging heart in health: links to heart disease. Circulation. 2003; 107(2): 346-54.
3. Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF, et al. Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study. JAMA. 1998; 279(8): 585-92.
4. Diaz VA, Mainous 3rd AG, Everett CJ, Schoepf UJ, Codd V, Samani NJ. Effect of healthy lifestyle behaviors on the association between leukocyte telomere length and coronary artery calcium. Am J Cardiol. 2010; 106(5): 659-63.
5. Lee HC, Wei YH. Oxidative stress, mitochondrial DNA mutation, and apoptosis in aging. Exp Biol Med (Maywood). 2007; 232(5): 592-606.
6. Lloyd-Jones DM, Leip EP, Larson MG, D'Agostino RB, Beiser A, Wilson PW, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation. 2006; 113(6): 791-8.
7. •• Forman DE, Rich MW, Alexander KP, Zieman S, Maurer MS, Najjar SS, Cleveland, Jr. JC, Krumholz HM, Wenger NK. Cardiac care for older adults: time for a new paradigm, white paper, JACC. in press. This American College of Cardiology White Paper focuses on the latest insights into the significant issues and developments pertaining to cardiac care in older adults.
8. • Barker CM, Forman DE, Rich MW, Feit F, McClurken JB, Cleveland, Jr JC, Murkherjee D, Alexander KP, Dangas GD. Interventional management of CAD in older adults, white paper, JACC in final edit. The authors present the latest developments pertaining to CAD requiring care beyond medication alone.
9. Ussher M, Ibrahim S, Reid F, Shaw A, Rowlands G. Psychosocial correlates of health literacy among older patients with coronary heart disease. J Health Commun. 2010; 15(7): 788-804.
10. Drageset J, Eide GE, Nygaard HA, Bondevik M, Nortvedt MW, Natvig GK. The impact of social support and sense of coherence on health-related quality of life among nursing home residents-a questionnaire survey in Bergen, Norway. Int J Nurs Stud. 2009; 46(1): 65-75.
11. Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, Meinow B, Fratiglioni L. Ageing with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011 Mar 11. [Epub ahead of print].
12. Forman DE, Cohen RA, Hoth KF, Haley AP, Poppas A, Moser DJ, et al. Vascular health and cognitive function in older adults with cardiovascular disease. Artery Res. 2008; 2(1): 35-43.
13. Kapp MB. Ethical aspects of guardianship. Clin Geriatr Med. 1994; 10(3): 501-12.
14. Zimring SD. Health care decision-making capacity: a legal perspective for long-term care providers. Am Med Dir Assoc. 2006; 7(5): 322-6.
15. Holst L, Lundgren M, Olsen L, Ishøy T. Dire deadlines: coping with dysfunctional family dynamics in an end-of-life care setting. Int J Palliat Nurs. 2009; 15(1): 34-41.
16. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004.
17. Neuman MD, Speck RM, Karlawish JM, Schwartz JS, Shea JA. Hospital protocols for the inpatient care of older adults: results from a statewide survey. J Am Geriatr Soc. doi: 10. 1111/j. 1532-5415. 2010. 03056. x.
18. Gottesman R. J Am Geriatr Soc. 2009; 57(11): 2029-36. Epub 2009 Sep 15.
19. •• Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA, ACCF/SCAI/STS/AATS/AHA/ASNC. Appropriateness criteria for coronary revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2009; 53: 530-53. This critical document will be updated in 2011.
20. •• Wijns W, Kolh P, Danchin N, Di Mario C, Falk V, Folliguet T, Garg S, Huber K, James S, Knuuti J, Lopez-Sendon J, Marco J, Menicanti L, Ostojic M, Piepoli MF, Pirlet C, Pomar JL, Reifart N, Ribichini FL, Schalij MJ, Sergeant P, Serruys PW, Silber S, Sousa Uva M, Taggart D, Vahanian A, Auricchio A, Bax J, Ceconi C, Dean V, Filippatos G, Funck-Brentano C, Hobbs R, Kearney P, McDonagh T, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Vardas PE, Widimsky P, Alfieri O, Dunning J, Elia S, Kappetein P, Lockowandt U, Sarris G, Vouhe P, von Segesser L, Agewall S, Aladashvili A, Alexopoulos D, Antunes MJ, Atalar E, Brutel de la Riviere A, Doganov A, Eha J, Fajadet J, Ferreira R, Garot J, Halcox J, Hasin Y, Janssens S, Kervinen K, Laufer G, Legrand V, Nashef SA, Neumann FJ, Niemela K, Nihoyannopoulos P, Noc M, Piek JJ, Pirk J, Rozenman Y, Sabate M, Starc R, Thielmann M, Wheatley DJ, Windecker S, Zembala M. Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2010; 31: 2501-55. The ESC/EACTS guidelines were just updated for myocardial revascularization in late 2010 and have new information, especially for decisions regarding PCI and CABG, including cardiac team approach.
21. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007; 356: 1503-16.
22. Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008; 117: 1283-91.
23. Alexander KP, Newby LK, Armstrong PW, Cannon CP, Gibler WB, Rich MW, et al. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007; 115: 2570-89.
24. Fox KA, Clayton TC, Damman P, Pocock SJ, de Winter RJ, Tijssen JG, et al. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol. 2010; 55: 2435-45.
25. •• Kappetein AP on behalf of the SYNTAX Investigators. Optimal revascularization strategy in patients with 3 vessel disease and/or left main disease: The 3-year outcomes of the SYNTAX Trial. Geneva: EACTS; 2010 This article provides landmark data on this large, real-world patient trial. The more complex the CAD, the less favorable is PCI when compared to CABG. LM PCI is an option with a favorable lesion. Cardiac Team opinion is offered for treatment options.
26. •• Serruys PW, Statler L, Boyce S, Mohr F, Feldman T, Kappetein AP, Colombo A, Mack M, Maurice M-C, Stahle E, Leadley K, Dawkins K, Holmes D. Three year followup of syntax trial: optimal revascularization strategy in patients with left main coronary artery disease. JACC. 2010; 56: B25. doi: 10. 1016/j. jacc. 2010. 08. 122This is the abstract for part of presentation of data from the SYNTAX investigators.
27. Ferguson Jr TB, Coombs LP, Peterson ED. Internal thoracic artery grafting in the elderly patient undergoing coronary artery bypass grafting: room for process improvement? J Thorac Cardiovasc Surg. 2002; 123: 869-80.
28. Ascione R, Rees K, Santo K, et al. Coronary artery bypass grafting in patients over 70 years old: the influence of age and surgical technique on early and mid-term clinical outcomes. Eur J Cardiothorac Surg. 2002; 22: 124-8.
29. Ivanov J, Weisel RD, David TE, Naylor CD. Fifteen-year trends in risk severity and operative mortality in elderly patients undergoing coronary artery bypass graft surgery. Circulation. 1998; 97: 673-80.
30. Natarajan A, Samadian S, Clark S. Coronary artery bypass surgery in elderly people. Postgrad Med J. 2007; 83: 154-8.
31. Moshkovitz Y, Paz Y, Shabtai E, et al. Predictors of early and overall outcome in coronary artery bypass without cardiopulmonary bypass. Eur J Cardiothorac Surg. 1997; 12: 31-9.
32. Loop FD, Lytle BW, Cosgrove DM, et al. Coronary artery bypass graft surgery in the elderly. Indications and outcome. Cleve Clin J Med. 1988; 55: 23-34.
33. Kurlansky PA, Williams DB, Traad EA, Zucker M, Ebra G. Eighteen-year follow-up demonstrates prolonged survival and enhanced quality of life for octogenarians after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2011; 141: 394-3993.
34. Loran DB, Zwischenberger JB. Thoracic surgery in the elderly. J Am Coll Surg. 2004; 199: 773-84.
35. Gardner TJ, Greene PS, Rykiel MF, et al. Routine use of the left internal mammary artery graft in the elderly. Ann Thorac Surg. 1990; 49: 188-93. discussion 93-4.
36. Kurlansky PA, Williams DB, Traad EA, et al. Arterial grafting results in reduced operative mortality and enhanced long-term quality of life in octogenarians. Ann Thorac Surg. 2003; 76: 418-26. discussion 27.
37. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 1999; 100: 1464-80.
38. He GW, Acuff TE, Ryan WH, Bowman RT, Douthit MB, Mack MJ. Determinants of operative mortality in elderly patients undergoing mortality and morbidity. J Thorac Cardiovasc Surg. 1994; 108: 73-81.
39. Mortasawi A, Arnrich B, Walter J, Frerichs I, Rosendahl U, Ennker J. Impact of age on the results of coronary artery bypass grafting. Asian Cardiovasc Thorac Ann. 2004; 12: 324-9.
40. • Sheridan BC, Stearns SC, Rossi JS, D'Arcy LP, Federspiel JJ, Carey TS. Three-year outcomes of multivessel revascularization in very elderly acute coronary syndrome patients. Ann Thorac Surg. 2010; 89: 1889-95. Excellent CABG outcomes are presented in very elderly patient cohort.
41. Alsaddique AA, Royse AG, Royse CF, Fouda MA. Management of diastolic heart failure following cardiac surgery. Eur J Cardiothorac Surg. 2009; 35: 241-9.
42. Hanon O, Baixas C, Friocourt P, Carrie D, Emeriau JP, Galinier M, et al. Consensus of the French Society of Gerontology and Geriatrics and the French Society of Cardiology for the management of coronary artery disease in older adults. Arch Cardiovasc Dis. 2009; 102: 829-45.
43. •• Peterson ED, Dai D, DeLong ER, Brennan JM, Singh M, Rao SV, Shaw RE, Roe MT, Ho KK, Klein LW, Krone RJ, Weintraub WS, Brindis RG, Rumsfeld JS, Spertus JA; NCDR Registry Participants. Contemporary mortality risk prediction for percutaneous coronary intervention: results from 588, 398 procedures in the National Cardiovascular Data Registry. J Am Coll Cardiol. 2010; 55(18): 1923-32 This is a huge (almost 500, 000) procedure series with the NCDR. It has a simplified 8-data point entry for risk assessment for PCI, including in older adults.
44. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009; 360: 961-72.
45. Chowdhary S, Ivanov J, Mackie K, Seidelin PH, Dzavik V. The Toronto score for in-hospital mortality after percutaneous coronary interventions. Am Heart J. 2009; 157: 156-63.
46. Negassa A, Monrad ES, Bang JY, Srinivas VS. Tree-structured risk stratification of in-hospital mortality after percutaneous coronary intervention for acute myocardial infarction: a report from the New York State percutaneous coronary intervention.
47. Singh M, Rihal CS, Lennon RJ, Spertus J, Rumsfeld JS, Holmes Jr DR. Bedside estimation of risk from percutaneous coronary intervention: the new Mayo Clinic risk scores. Mayo Clin Proc. 2007; 82: 701-8.
48. Berger PB, Bhatt DL, Fuster V, Steg PG, Fox KA, Shao M, et al. Bleeding complications with dual antiplatelet therapy among patients with stable vascular disease or risk factors for vascular disease: results from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial. Circulation. 2010; 121: 2575-83.
49. Sadeghi HM, Grines CL, Chandra HR, Dixon SR, Boura JA, Dukkipati S, et al. Percutaneous coronary interventions in octogenarians. glycoprotein IIb/IIIa receptor inhibitors' safety profile. J Am Coll Cardiol. 2003; 42: 428-32.
50. •• Lee DH, Buth KJ, Martin BJ, Yip AM, Hirsch GM. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation. 2010; 121: 973-78. It is useful to know the likelihood of requiring hospitalization post care.
51. • Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010; 210: 901-08. This article makes clear the different simple assessments for frailty.
52. • Sündermann S, Dademasch A, Praetorius J, Kempfert J, Dewey T, Falk V, Mohr FW, Walther T. Comprehensive assessment of frailty for elderly high-risk patients undergoing cardiac surgery, Eur J Cardiothorac Surg. 2010. This article reviews frailty assessments with cardiac surgery.
53. • Freiheit EA, Hogan DB, Eliasziw M, Meekes MF, Ghali WA, Partlo LA, Maxwell CJ. Development of a frailty index for patients with coronary artery disease. J Am Geriatr Soc. 2010; 58: 1526-31. This is another frailty scoring tool.
54. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiender J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156. 34.
55. Purser J. Identifying frailty in hospitalized older adults with significant coronary artery disease. J Am Geriatr Soc. 2006; 54(11): 1674-81.
56. Rengo G, Galasso G, Piscione F, Golino G, Fortunato F, Zincarelli C, et al. An active lifestyle improves outcome of primary angioplasty in elderly patients with acute myocardial infarction. Am Hear J. 2007; 154(2): 352-60.
57. Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg. 1999; 16: 9-13.
58. Nashef SA. EuroSCORE and heart valve surgery. J Heart Valve Dis. 2010; 19: 1-4.
59. Rekik S, Brunet J, Bayet G, et al. EuroSCORE s a good global predictor of long-term outcomes in high risk but not in low-risk patients after unprotected left main angioplasty. Catheter Cardiovasc Interv. 2010.
60. Iyem H. Evaluation of the reliability of the EuroSCORE risk analysis prediction in high-risk older patients undergoing CABG. Cardiovasc J Afr. 2009; 20: 340-3.
61. Li Y, Zheng Z, Hu S. Early and long-term outcomes in the elderly: comparison between off-pump and on-pump techniques in 1101 patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2008; 136: 657-64.
62. • Euroscore Official Website http://www. euroscore. org/euroscore_scoring. htm. This is a very easy to use risk calculator tool.
63. Ferguson TB JR, Hammill BG, Peterson ED, DeLong ER, Grover FL. A decade of change-risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990-1999: a report from the STS National Database Committee and the duke Clinical Research Institute. Society of Thoracic Surgeons. Ann Thorac Surg. 2002; 73: 480-9. discussion 9-90.
64. • STS Database Risk Calculator. http://209. 220. 160. 181/STSWebRiskCalc261/. 2011. This the scoring tool commonly utilized in the United States for cardiac surgery risk assessment.
65. Afilalo J, Eisenberg MJ, Morin JF, Bergman H, Monette J, Noiseux N, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010; 56(20): 1668-76.
66. •• Bauer T. Int J Cardiology. 2010; doi: 10. 1016/j. ijcard. 2010. 05. 006. This is a dramatic demonstration of simple walk test correlating with surgical stratified outcomes.
67. Reicher B, Poston RS, Mehra MR. Simultaneous "hybrid" percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinicaloutcomes. Am Heart J. 2008; 155: 661-7.
68. • Bhamidipati GM, LaPar DJ, Fonner E Jr, Kern JA, Kron IL, Ailawadi G. Outcomes and cost of cardiac surgery in octogenarians is related to type of operation: a multiinstitutional analysis. Ann Thorac Surg. 2011; 91(2): 499-505. This is a large review of outcomes and cost in patients > 80 years of age undergoing contemporary heart surgery in Virginia.
69. Niederman MS, Berger JT. The delivery of futile care is harmful to other patients. Crit Care Med. 2010; 38: S518-22.
70. McCabe MS, Storm C. When doctors and patients disagree about medical futility. J Oncol Pract. 2008; 4: 207-9.