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Advanced and Expensive Cardiovascular Procedures in the Very Elderly–Can We or Should We Limit Access?

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Book cover Controversies in Cardiology

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Abstract

With the increasing proportion of elderly patients in the population, physicians are often faced with challenging treatment decisions for the management of coronary artery diseases, valvular heart diseases, advanced heart failure and prevention of sudden cardiac death in the elderly patient population. Comprehensive review of the literature and available evidence is summarized in this chapter to guide such complex clinical decisions. Elderly patients presenting with an acute coronary syndrome (ACS) appear to benefit from percutaneous coronary intervention (PCI) with the use of drug eluting stents (DES). Though current guidelines do not consider age as a prohibitive factor, the risk of major bleeding complications and stroke should be carefully considered. For elderly patients with severe aortic stenosis, trans-catheter aortic valve replacement (TAVR) is superior compared to medical therapy for inoperable patients. TAVR, when performed via the transfemoral approach, remains non inferior and cost effective compared to surgical aortic valve replacement (SAVR). Trans-catheter mitral valve repair (TMVR) using MitraClip appears to be beneficial for inoperable patients with degenerative severe mitral regurgitation but more data are needed. Implantable cardioverter defibrillator (ICD) implantation in the elderly population remains a controversial topic especially for secondary prevention. The current evidence suggests that age should not be the sole withholding factor but the decision for ICD implantation should account for comorbidities and patient preference. On the other hand, cardiac resynchronization therapy (CRT) has definitely a mortality and morbidity benefit in the management of elderly patients with advanced heart failure.

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Abbreviations

ASSENT:

Assessment of the Safety and Efficacy of a New Thrombolytic

AVID:

The Antiarrhythmic vs Implantable Defibrillators

CARE-HF:

Cardiac Resynchronization in Heart Failure study

CASH:

Cardiac Arrest Study Hamburg

CIDS:

Canadian Implantable Defibrillator Study

COMPANION:

The Comparison of Medical Pacing and Defibrillator Therapies in Heart Failure Trial

EVEREST:

Endovascular Valve Edge-to-Edge Repair Study

GUSTO:

Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries

HERO:

Hirulog Early Reperfusion or Occlusion

MADIT–CRT:

Multicenter Automatic Defibrillator Implantation trial with Cardiac Resynchronization Therapy

MADITT-II:

Multicenter Automatic Defibrillator Implantation Trial-II

MIRACLE:

Multicenter InSync ICD Randomized Clinical Evaluation

PAMI:

Primary Angioplasty in Myocardial Infarction

PARAGON:

The Platelet IIb/IIIa Antagonist for the Reduction of Acute coronary syndrome events in a Global Organization Network

PARTNER:

Placement of Aortic Transcatheter Valve

PURSUIT:

The Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy

TACTICS-TIMI 18:

Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy--Thrombolysis in Myocardial Infarction 18

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Authors and Affiliations

  1. Department of Cardiology, Christiana Care Health System, Newark, DE, USA

    Pranav Kansara MD, MS, Konstantinos Kossidas MD, Sandra Weiss MD, FACC & William S. Weintraub MD, MACC

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  1. Pranav Kansara MD, MS
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  2. Konstantinos Kossidas MD
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  3. Sandra Weiss MD, FACC
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  4. William S. Weintraub MD, MACC
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Editors and Affiliations

  1. UCSF Fresno, Fresno, California, USA

    John A. Ambrose

  2. Department of Interventional Cardiology, Otamendi Hospital, Buenos Aires, Argentina

    Alfredo E. Rodríguez

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Kansara, P., Kossidas, K., Weiss, S., Weintraub, W.S. (2015). Advanced and Expensive Cardiovascular Procedures in the Very Elderly–Can We or Should We Limit Access?. In: Ambrose, J., Rodríguez, A. (eds) Controversies in Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-319-20415-4_25

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  • DOI: https://doi.org/10.1007/978-3-319-20415-4_25

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  • Online ISBN: 978-3-319-20415-4

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