You're never too old

Current treatment of symptomatic aortic stenosis in elderly patients: Do risk scores really matter after 80 years of age?

BACKGROUND

According to the guidelines, surgical aortic valve replacement (SAVR) is recommended in patients at low surgical risk (EuroSCORE II<4%), whereas for other patients, the decision between transcatheter aortic valve implantation (TAVI) and surgery should be made by the Heart Team, with TAVI being favoured in elderly patients.

AIM

The RAC prospective multicentre survey assessed the respective contributions of age and surgical risk scores in therapeutic decision making in elderly patients with severe symptomatic aortic stenosis.

METHODS

In September and October 2016, 1049 consecutive patients aged ≥ 75 years were included in 32 centres with on-site TAVI and surgical facilities. The primary endpoint was the decision between medical management, TAVI or SAVR.

RESULTS

Mean age was 84±5 years and 53% of patients were female. The surgical risk was classified as high (EuroSCORE II>8%) in 18% of patients, intermediate (EuroSCORE II 4-8%) in 34% and low (EuroSCORE II≤4%) in 48%. TAVI was preferred in 71% of patients, SAVR in 19% and medical treatment in 10%. The choice of TAVI over SAVR was associated with older age (P<0.0001) and a higher EuroSCORE II (P=0.008). However, the weight of EuroSCORE II in therapeutic decision making markedly decreased after the age of 80 years. Indeed, 77% of patients aged ≥ 80 years were referred for TAVI, despite a low estimated surgical risk.

CONCLUSIONS

The impact of risk scores depends strongly on age, and decreases considerably after 80 years, most patients being referred for TAVI, independent of their estimated surgical risk. Despite medical advancements, 10% of patients were still denied any intervention.

Elder Care Versus Adult Care

This study compares employed persons caring for disabled adults age 18-64 with those caring for persons 65 or older, using a stratified random sample of 4,256 university employees age 30 or older. About 10% of employees were providing assistance to an adult age 18-64 and 17% to an adult age 65 or older. Employees assisting someone 18-64 provided higher levels of care than those assisting someone 65 or older; in addition, they experienced higher levels of caregiving strain and comparable levels of work interference and general role strain, after controlling for sociodemographic characteristics, caregiving demands and resources, and job demands and resources. Caregiving research and policy formation need to address the growing number of family members providing assistance to disabled adults under the age of 65 as well as those providing elder care.

Management and outcomes of severe aortic stenosis in cancer patients

BACKGROUND

Aortic stenosis (AS) is the commonest native valve lesion, affecting 43% of all patients with valvular heart disease. The optimal treatment of severe AS in cancer patients is unknown. The purpose of this study was to assess the impact of aortic valve replacement (AVR) on survival of cancer patients with severe AS.

METHODS

Cancer patients with severe AS seen at our center between January 2001 and April 2007 were identified. Baseline demographics, symptoms, cancer diagnosis, laboratory data, treatment, and outcome were collected. Patient who had AVR were matched with controls who did not have AS.

RESULTS

Out of 39,071 echocardiograms performed over the study period, 1,299 had AS (3.3%), of which 50 patients (0.13%) were identified as having severe AS. Thirteen patients (27%) underwent AVR, and 35 were managed medically. Two patients underwent valvuloplasty and were excluded. Survival was significantly longer in patients with severe AS who underwent AVR and was independent of cancer status or presence of metastases. No difference in survival was found between patients who underwent AVR and matched cancer controls. In a multivariable Cox proportional hazard regression analysis, AVR was the only significant predictor of longer survival (adjusted hazard ratio = 0.22, P = .028).

CONCLUSIONS

Cancer patients with severe AS who underwent AVR had an improved survival, regardless of cancer status.

High Technology Therapies and Older People

Therapies to save or sustain the lives of elderly patients are sometimes used when they can bring little benefit, and sometimes denied because of age to patients who could benefit. Selection for treatment should depend on balancing probable benefits and burdens for the patient and on the patient's preferences. Burdens include those of the treatment itself, the risk of complications and of extending life of poor quality. Factors to consider when deciding are illustrated by reference to intensive care, surgery, dialysis, cardiopulmonary resuscitation and tube feeding.

Outcome of elderly patients undergoing open-heart surgery in a developing country

To evaluate and compare the outcome of open-heart surgery in elderly patients with a concurrent group of younger patients in a developing country, data of all adult patients who underwent open-heart surgery during the period of 3 years from January 1999 to December 2001 were collected prospectively. Demographic data such as age and gender, other data such as preoperative diagnoses, comorbid illnesses, type of surgery, time of cardio-pulmonary bypass, length of stay and hospital outcome were recorded. The characteristics of patients above the age of 65 years were compared with a concurrent cohort of patients aged less than 65 years. One hundred and forty-five adult patients underwent open-heart surgeries in 3 years, and the overall mortality rate was 4.8%. The much common surgeries were coronary artery bypass grafting, valve repair/replacement surgery and surgery for adult congenital heart diseases. Forty-five (31%) patients were above the age of 65 years. The mortality rate was 2.2% for patients who were aged 65 years and above, in comparison with that of the concurrent cohort of younger patients (6%). This was probably because of more number of surgeries for congenital heart diseases in the latter group. However, even with other surgeries such as coronary artery bypass grafting, the elderly group of patients did equally well as the younger group. Elderly patients tolerate cardiac surgery well, and age should not be an exclusive criterion to decide against open-heart surgery.

Importance of risk communication and decision making in cardiovascular conditions in older patients: a discussion paper

Atrial fibrillation and aortic stenosis commonly present doctors and patients with difficult decisions about the risks and benefits of treatment options and are both often inappropriately undertreated. Patients may be confused by risk information and doctors may be aware of patients' limitations and use this to manipulate choices to the ones desired by the doctors. This paper examines the importance of risk communication and discusses difficulties that can arise in decision making in these two common cardiovascular conditions.

Timing of surgery in aortic stenosis

In adults with valvular stenosis, the importance of prompt aortic valve replacement once symptoms occur is well known. The operative mortality for aortic valve replacement has improved dramatically over the past 4 decades and remains the only effective therapy for severe symptomatic aortic stenosis. Aortic valve replacement in patients with left ventricular dysfunction has a high operative mortality, although those patients who do not undergo surgery at all have an even worse outcome. While issues to consider include the presence or absence of coronary artery disease and expected hemodynamics of the prosthetic valve compared with the native valve, when in doubt, one should err on the side of surgical intervention. Elderly age is not a contraindication to aortic valve replacement for severe symptomatic aortic stenosis, although there is a higher prevalence of comorbid disease and higher operative mortality. Life expectancy is significantly prolonged and quality of life is significantly improved in the elderly who survive surgery. Indications for surgery in asymptomatic patients are controversial. We do not recommend valve replacement in asymptomatic patients at this time due to the known risks of surgery and a prosthetic valve and the lack of evidence for benefit of early surgery. Patients undergoing coronary bypass surgery should be considered for concomitant aortic valve surgery for moderate aortic stenosis that is expected to progress to severe stenosis in less than 5 years.

Variability in treatment advice for elderly patients with aortic stenosis: a nationwide survey in The Netherlands

OBJECTIVE

To determine how the decisions of Dutch cardiologists on surgical treatment for aortic stenosis were influenced by the patient's age, cardiac signs and symptoms, and comorbidity; and to identify groups of cardiologists whose responses to these clinical characteristics were similar.

DESIGN

A questionnaire was produced asking cardiologists to indicate on a six point scale whether they would advise cardiac surgery for each of 32 case vignettes describing 10 clinical characteristics.

SETTING

Nationwide postal survey among all 530 cardiologists in the Netherlands.

RESULTS

52% of the cardiologists responded. There was wide variability in the cardiologists' advice for the individual case vignettes. Six groups of cardiologists explained 60% of the variance. The age of the patient was most important for 41% of the cardiologists; among these, 50% had a high and 50% a low inclination to advise surgery. A further 24% were influenced equally by the patient's age and by the severity of the aortic stenosis and its effect on left ventricular function; among these, 62% had a high and 38% a low inclination to advise surgery. Finally, 23% of the cardiologists were mainly influenced by the left ventricular function and 12% by the aortic valve area. The presence of comorbidity always played a minor role.

CONCLUSIONS

There were systematic differences among groups of cardiologists in their inclination to advise aortic valve replacement for elderly patients, as well as in the way their advice was influenced by the patients' characteristics. These results indicate the need for prospective studies to identify the best treatment for elderly patients according to their clinical profile.

To operate or not on elderly patients with aortic stenosis: the decision and its consequences

OBJECTIVE

To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in elderly patients.

DESIGN

Cohort analysis based on a prospective inclusive registry.

SETTING

205 consecutive patients (>/= 70 years) with clinically relevant isolated aortic stenosis and without serious comorbidity, seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands.

RESULTS

The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement according to the practice guidelines were actually offered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high gradient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients with a high baseline risk, mainly determined by impaired left ventricular function, had a significantly better three year survival with surgical treatment than with medical treatment.

CONCLUSIONS

In daily practice, elderly patients with clinically relevant symptomatic aortic stenosis are often denied surgical treatment. This study indicates that a surgical approach, especially where there is impaired systolic left ventricular function, is associated with better survival.

Age as a basis for healthcare rationing. Arguments against agism

Age alone is a poor marker of disability. Decision making in medicine should be based on potential benefit to the individual. Most healthcare expenditure on the elderly is for routine care, which few could argue should be denied because of age. Healthcare reforms that encourage functional independence and community based care of the elderly are more likely to lead to cost savings than simple rationing according to age. Treatment options previously thought futile in the elderly, particularly surgical interventions and drug therapy for cardiovascular disease, have been shown to be effective in terms of improved health and cost benefit. Thus, discrimination on the basis of age (agism) is not only ethically unacceptable in a society embracing principles of justice and equity, but also unsupportable on scientific and/or economic analysis.

The utilization of antithrombotic prophylaxis for atrial fibrillation in a geriatric rehabilitation hospital

OBJECTIVE

To determine the utilization of anticoagulant and antithrombotic agents in older patients with atrial fibrillation.

DESIGN

Retrospective chart review.

SETTING

A geriatric rehabilitation hospital.

PATIENTS

Subjects were 102 patients with atrial fibrillation as an intermittent or prevailing cardiac rhythm during a hospital admission in the 1993 fiscal year.

MEASUREMENTS

Age, sex, and mental status of the patients; duration and etiology of atrial fibrillation; presence of contraindications to anticoagulants or antithrombotic agents; and utilization of these agents in this population.

RESULTS

Of 102 older patients with atrial fibrillation at admission, only 51 were taking some form of anticoagulant or antithrombotic therapy proven effective for stroke prophylaxis (19 warfarin and 32 aspirin). Although 67 patients had relative contraindications to anticoagulation with warfarin, only 25 of the 35 with no contraindications were taking warfarin at the time of discharge. In addition, of the 43 patients with contraindications to warfarin but no contraindications to aspirin, only 28 were prescribed antithrombotic therapy.

CONCLUSIONS

Although anticoagulation or antithrombotic therapies for atrial fibrillation appear to be relatively widely used, there are still significant windows of opportunity for the improvement of clinician practice patterns and clinical outcomes in older patients.

Pancreatic or liver resection for malignancy is safe and effective for the elderly

BACKGROUND

Liver resection, or pancreaticoduodenectomy, has traditionally been thought to have a high morbidity and mortality rate among the elderly. Recent improvements in surgical and anesthetic techniques, an increasing number of elderly patients, and an increasing need to justify use of limited health care resources prompted an assessment of recent surgical outcomes.

METHODS

Five hundred seventy-seven liver resections (July 1985-July 1994) performed for metastatic colorectal cancer and 488 pancreatic resections (October 1983-July 1994) performed for pancreatic malignancies were identified in departmental data bases. Outcomes of patients younger than age 70 years were compared with those of patients age 70 years or older.

RESULTS

Liver resection for 128 patients age 70 years or older resulted in a 4% perioperative mortality rate and a 42% complication rate. Median hospital stay was 13 days, and 8% of the patients required admission to the intensive care unit (ICU). Median survival was 40 months, and the 5-year survival rate was 35%. No differences were found between results for the elderly and those for younger patients who had undergone liver resection, except for a minimally shorter hospital stay for the younger patients (median, 12 days vs. 13 days; p = 0.003). Pancreatic resection for 138 elderly patients resulted in a mortality rate of 6% and a complication rate of 45%. Median stay was 20 days, and 19% of the patients required ICU admission, results identical to those for the younger cohort. Long-term survival was poorer for the elderly patients, with a 5-year survival rate of 21% compared with 29% for the younger cohort (p = 0.03).

CONCLUSIONS

Major liver or pancreatic resections can be performed for the elderly with acceptable morbidity and mortality rates and possible long-term survival. Chronological age alone is not a contraindication to liver or pancreatic resection for malignancy.

Coronary artery disease, valvular heart disease, bradycardia, and heart failure

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