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

I have no conflict of interest to report with regards to this presentation.

Age 94 yrs

Silver Tsunami

Source: Straits Times

Life Expectancy at Birth S’pore & Demographic changes with time

Spore Govt Statistics

Spore Govt Statistics

Spore Myocard Infarct Registry(SMIR) STEMI & NSTEMI incidence rates: 2008-2017

Accessed 29sep2019: SMIR-NDRO Spore

How to manage these Elderly patients

when they develop ACS?

Approach to ACS

Low

Risk

• Ischaemia guided strategy

High

Risk

• Early Invasive Management

RISK SCORE ASSESSMENT

DAPT LMWH

TACTICS-TIMI 18

CP Cannon et al. NEJM 2001; 344: 1879-87

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

GRACE Score

KA Eagle et al. JAMA 2004; 291: 2727-33

ACS-TIMI Risk Score Stratification

CP Cannon et al. NEJM 2001; 344: 1879-87

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

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

ACS Case illustration: 80yr male ACS with pneumonia

Pre PCI Pre PCI

Pre PCI Pre PCI

Pre PCI- failed IVUS Pre PCI RCA

1.5 burr to OLCX RA 1.5 burr to LM-LAD

Post POBA to both LM-LAD & LCX

Post OLCX burr

Culotte LM into OLCX DES to LM-LAD

Final Kissing inflations

Angio final LM-LAD-LCX

Rao cranial Final-spider

RCA

RCA post stenting final RCA rotablation

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

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

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

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

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

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

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

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

Co-morbidities:After 80 study

N Tegn et al. Lancet 2016; 387: 1057-65

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

VERDICT

KF Kofoed et al. CIRC 2018; 138: 2741-50

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

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.

Radial vs Femoral Access in ACS-PCI: Meta-analysis

M Valgimigli et al. Lancet 2015; 385: 2465-76

Further issues that occurs more commonly with ACS-PCI in Elderly

• Complex lesions, Multivessel Disease

• Calcified

• Left Main

• Increased risk of renal injury

EXCEL Trial: ACS in LM PCI

S Doucet et al. Am Hrt J 2019; 214: 9-17

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

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.

2016 ACC/AHA guidelines

:

DAPT Duration

in ACS

GL Levine et al. Circ 2016: 134: e123-55

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

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

Singapore Case Fatality Rates in STEMI & NSTEMI: 2008-2017

AMI : STEMI vs NSTEMI

Accessed 29sep2019: SMIR-NDRO Spore

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

• 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

National Heart Centre, Singapore

THANK YOU

After 80: Influence of Age on Primary Endpoint

uncertain benefit if age >90yr

N Tegn et al. Lancet 2016; 387: 1057-65

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

REDUCE Trial

DAPT 6 vs 12 mths in

Elderly pt with 2nd

Geneneration DES

SY Lee et al. JACCIntv 2018; 11:435-43

SY Lee et al. JACCIntv 2018; 11:435-43

SY Lee et al. JACCIntv 2018; 11:435-43

NOAC & P2Y12 inhibitor vs Vit K+DAPT:

Pooled Outcomes: Safety & Efficacy

P Vranckx et al. Lancet 2019

online sep 3

Pooled Trials of NOAC+P2Y12

Inhibition vs Vit K +DAPT

P Vranckx et al. Lancet 2019

online sep 3