Coronary artery disease intervention considerations in elderly patients

Coronary Artery Disease Intervention Considerations in Elderly Patients A/Prof Phạm Mạnh Hùng, MD.FACC.FESC Director Cardiac Cath.Lab – Vietnam Heart Institute Secretary General – Vietnam Heart Association PCI Patient Case • 83 year old male, small NSTEMI, moderate LMCA, vessel disease, AAA, moderate MR, chronic atrial fibrillation, diabetes • How to proceed? • • • • (CAD) Interventionalist – PCI; (AAA) Stent Graft? Surgeon – CABG General Cardiologist – medication Patient - Are they even in the decision making process?? Cor Angio Treatment Methods Selection • Medical ? • Surgery? • Intervention? To intervene or not??? Coronary disease AAA Complex Trade-offs • Clinical Questions: • • • • • • • • • • Optimal medical therapy?, PCI ?, DES/BMS?, CABG? 1, 2, or vessel, LMCA involvement and % stenosis? Anatomy suitable – SYNTAX Score? Severity of ischemia? Diabetic? LV function and concomitant valvular disease? Other co-morbidities? Prior PCI or CABG? Potential future elective non-cardiac surgery? Patient ability for maintaining clopidogrel adherence? Goals of Coronary Revascularization • • • • Positively impact longevity/mortality Improvement in health status/symptoms Ability to influence either is not equal for all clinical scenarios Longevity gains limited to selective patient scenarios - PCI vs CABG Effects of Aging on Coronary Arteries  Dilation  Tortuosity  Medial calcification  Impaired endothelial function Effects of Aging on Ventricular Function   diastolic filling,  LVEDP   afterload (arterial stiffening)   myocardial thickness  Filling more dependent on atrial kick  Prolonged time of relaxation  Lower EF  Lower cardiac output Paclitaxel-Eluting Stent Outcomes in the Elderly Circ Cardiovasc Intervent 2009;2:178-187 TIME: Randomized trial of Invasive vs Medical Therapy Age > 75 yrs, chronic angina Lancet 2001; 358: 951-957 FRISC II Benefit of an Invasive Strategy in NSTEACS: Greatest in patients > 65 years of age Death or MI at Months Age