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Bill Weintraub : NCDR Founding Father

Bill Weintraub : NCDR Founding Father. “Science tells us what we can do; Guidelines what we should do; Registries what we are actually doing.”. NCDR Temporal Experience. Exclusion of > 75 Yrs from Cardiac RCTs Review of 593 UA/MI Trials. Trials Not Including Elderly (%). Lee, JAMA 2001.

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Bill Weintraub : NCDR Founding Father

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  1. Bill Weintraub :NCDR Founding Father

  2. “Science tells us what we can do; Guidelines what we should do; Registries what we are actually doing.”

  3. NCDR Temporal Experience

  4. Exclusion of >75 Yrs from Cardiac RCTsReview of 593 UA/MI Trials Trials Not Including Elderly (%) Lee, JAMA 2001

  5. NSTE ACS in ElderlyIn-Hospital Events * Kulkarni S et al ACC 2003 CRUSADE Presentation

  6. Therapeutics in ACS Among Patients >90 Years Old Mortality Major Bleeding Optimal Even among oldest old – better outcomes with better adherence to ACC/AHA Guidelines - Skolnick et al, ACC 2006

  7. Inherent or Induced Problem?Excessive Antithrombotic Dosing by Age Alexander KA, JAMA 2005

  8. AHA Consensus Group on Management of ACS in the Elderly Renal Function and Age NonSTEMI ACS (GRACE) Patient Age 23,694 13,033 13,835 6,401 N= Renal Insuff defined as Serum Creat >2.0mg/dl

  9. Post-MI Testing by Age CategoryMedicare Alexander 2001 AHJ

  10. Invasive Procedure Use by Age Alexander KA, JACC 2005;46:1479-87.

  11. 0.5 1 1.5 2 Predictors of Early Cath in CRUSADE Cardiology Care Age (per 10 yrs) Prior CHF Renal Insufficiency Signs of CHF Caucasian Race Female Sex Adjusted Odds Ratio Bhatt et al, JAMA 2004

  12. In-Hospital Mortality by Age and Guidelines Adherence: Observations from CRUSADE Age Group Adj. OR: 0.71 (0.67-0.75)0.79 (0.75-0.83) - Boden et al, AHA 2005

  13. The Oldest Old (>90 years) with ACS: Observations From CRUSADE CQI CRUSADE Population N: 142,335 Death MI Bleeding 7.8% 3.5% 13.1% 12.0% 3.0% 9.9% The Elderly (age >75) N: 46,270 – 33% Oldest Old (age >90) N: 5,557 – 4% - Skolnick et al, ACC 2006

  14. Reason for No Cath Contraindication Among 9,884 High-Risk ACS Patients

  15. Secondary Prevention: It Works at all Ages! • Similar benefits of aspirin/beta-blockers: CCP • Similar benefits of ace-inhibitors: HOPE • Similar benefits of lipid lowering: HPS • Similar improvements in functional outcomes with Cardiac Rehab: Pasquali 2002 ACC

  16. Less Prevention Management Among Elderly Out-Patients in REACH - Hirsch et al, ACC 2006

  17. Registry/QI • 1100 hospitals • >9 million patient records • Online data entry tool • Support D2B Alliance Research and Publications • DCRI analytic center • Over 100 publications

  18. NCDR : Age and PCI Mortality 2001-2006 In-Hospital PCI Mortality = 1.22% Mortality (%) Age <40 40-59 60-79 80 n=25,679 n=496,204 n=732,574 n=155,612 Singh M et.al Circ CardiovascIntervent 2009;2:20-26

  19. Age 40 40-59 69-79 80 NCDR Trends : Age and PCI Mortality Overall PCI Patients= 1.22% Mortality (%) 2001 2002 2003 2004 2005 2006 Years Singh M et.al Circ CardiovascIntervent 2009;2:20-26

  20. Age 40 40-59 69-79 80 NCDR Trends : Age and PCI Mortality Elective PCI Patients Mortality (%) 2001 2002 2003 2004 2005 2006 Years Singh M et.al Circ CardiovascIntervent 2009;2:20-26

  21. Age 40 40-59 69-79 80 NCDR Trends : Age and PCI Mortality Urgent/Emergent/Salvage PCI Patients Mortality (%) 2001 2002 2003 2004 2005 2006 Years Singh M et.al Circ CardiovascIntervent 2009;2:20-26

  22. Society of Thoracic Surgery Risk Calculator • STS National Database website: • www.sts.org/sections/stsnationaldatabase/riskcalculator/ • 85 yo, female, African-American, isolated first time CABG, 80kg, Diabetic on insulin, Creatinine 2.2, mild COPD, HX of Cerebrovascular Disease, no CVA, small NSTEMI, mild CHF, Chronic Atrial Fibrillation, 3 vessel/LMCA disease, 40% ejection fraction, moderate MR, mild TR, mild AS

  23. Society of Thoracic Surgery Risk Calculator • 85 yo female small NSTEMI for isolated CABG • Mortality 27% • 70% Morbidity or Mortality • 61% Increased length of stay • 57% Prolonged ventilation • 47% Renal failure 19% Reoperation Rate • 10% Permanent stroke • 2.2% Deep Sternal Wound

  24. Revascularization in Older Persons with Chronic CAD Acute Risks: CABG Mortality % Mortality Cheitman M, et alAm J Geritri Cards 2001;10:207-223

  25. Appropriate Use Criteria J Am Coll Cardiol 2009; 53;530-553 Available at http://www.acc.org

  26. What are Appropriateness Use Criteria? • Define “what to do”, “when to do”, and “how often to do” in the context of local care environments combined with patient and family preferences and values • Address misuse, overuse and underuse • Connected to guideline content • Imply a level of detail and complexity that extends beyond the current recommendations

  27. Appropriateness Use Criteria Modified Rand/Delphi Methodology Define “Appropriateness” for Coronary Revascularization The WritingCommittee “Coronary revascularization is appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the expected negative consequences of the procedure”

  28. Framework for Decision MakingFive Core Variables Highrisk LM +3v CAD STEMI Class IV Max A MEDICAL Rx SYMPTOMS STABILITY ANATOMY ISCHEMIA U I Stable angina Class I ASx None Low risk No sig.CAD None

  29. Clinical Scenarios –Patients without prior CABG Revascularization CTO of 1 v (in the absence of other disease)or 1-2 v disease (no LAD) Asymptomatic or low risk noninvasive findings = U I

  30. SharedDecision-making • Collaboration in decision-making between physician and patient • Physician’s role: Communicate information on harms/benefits of test or treatment • Patient’s role: To provide information about values, preferences, lifestyle, beliefs • Goal: Treatment decisions are evidence-based and are reflective of the patient’s values and preferences

  31. Willingness to Consider an Invasive Cardiac Procedure by Age Alexander K 2006

  32. Importance of Quality of Life versus Quantity of Life “ It is with the elderly that some of the contradictions of modern medicine are cast in clearest relief. ….It is a rare older individual who has not accepted his or her mortality. In this light, the concept of ‘conquering disease’ loses some of its romance.” - James Goodwin MD Goodwin, JAMA, 1997

  33. “What are the most important goals from the treatment of your heart disease?”

  34. Patient Case 85 year old female, small NSTEMI, 3 vessel disease • Ischemic burden on stress testing • Medical therapy options • PCI and CABG options • Expectation for relief from angina for each • “Customized” to patient’s needs and values

  35. Advanced Coronary Heart Disease: Scope of the Problem in an Aging Population Conclusions • Advanced CAD is increasingly a greater challenge in CV medicine • High morbidity and mortality • The elderly and those with advanced CAD should receive evidenced based treatment strategies in ACS • Appropriate medical therapies are underused • A targeted invasive approach may be of benefit, if focused on quality of life • A multi-disciplinary approach is required that involves physical and emotional support

  36. Evidence-based Guidelines & Patients with Multiple Conditions A Balancing Act in Older Persons Evidence-basedTherapies PersonalizedCare

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