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 RCTsReview of 593 UA/MI Trials

Exclusion of >75 Yrs from Cardiac RCTsReview of 593 UA/MI Trials

0

1020

3040

50

6070

8090

100

1966-70 1971-80 1981-90 1991-95 1996-00

Explicit Exclusion>75 No Pt >75 enrolled

Lee, JAMA 2001

Tri

als

No

t In

clu

din

g E

lder

ly (

%)

Tri

als

No

t In

clu

din

g E

lder

ly (

%)

NSTE ACS in ElderlyIn-Hospital Events

NSTE ACS in ElderlyIn-Hospital Events

2.8

67.4

8.5

13.3

16.1

02468

1012141618

Death Death/MI CHF

<75 Years >75 Years

* Kulkarni S et al ACC 2003 CRUSADE Presentation

Therapeutics in ACS Among Patients >90 Years Old

Therapeutics in ACS Among Patients >90 Years Old

In-hospital Mortality by Number of Therapies

0

5

10

15

20

25

30

None One Two Three Four Five

Number of Recommended Therapies* (p<0.001 for trend)

% m

ort

alit

y

Age 75-89

Age 90 and older

Major Bleeding by Number of Therapies

0

2

4

6

8

10

12

14

16

18

20

None One Two Three Four FiveNumber of Recommended Therapies*

(p<0.01 for trend) (CABG Pts and contraindications excluded)

% m

ajo

r b

leed

ing

**

Age 75-89

Age 90 and older

MortalityMortality Major BleedingMajor Bleeding

Even among oldest old – better outcomes with better adherence to ACC/AHA Guidelines

Even among oldest old – better outcomes with better adherence to ACC/AHA Guidelines

OptimalOptimal

- Skolnick et al, ACC 2006- Skolnick et al, ACC 2006

Inherent or Induced Problem?Excessive Antithrombotic Dosing by Age

Inherent or Induced Problem?Excessive Antithrombotic Dosing by Age

12.5

28.7

8.512.8

3733.1

16.5

38.5

64.5

0

10

20

30

40

50

60

70

LMW Heparin UF Heparin GP IIb/IIIa

% E

xcessiv

e D

ose

< 65 yrs 65-75 yrs >75 yrs

12.5

28.7

8.512.8

3733.1

16.5

38.5

64.5

0

10

20

30

40

50

60

70

LMW Heparin UF Heparin GP IIb/IIIa

% E

xcessiv

e D

ose

< 65 yrs 65-75 yrs >75 yrs

Alexander KA, JAMA 2005Alexander KA, JAMA 2005

0102030405060708090

100

<65 65-74 75-84 >85

BMI (kg/m2)CrCl (ml/min)Renal Insuff (%)

23,694 13,033 13,835 6,401N=

Patient Age

Renal Insuff defined as Serum Creat >2.0mg/dl

AHA Consensus Group on Management of ACS in the Elderly

AHA Consensus Group on Management of ACS in the Elderly

Renal Function and Age NonSTEMI ACS (GRACE)

0

10

20

30

40

50

60

Cath Stress Test Revasc

% A

MI P

atie

nts

65-69 70-74 75-79 >80 Alexander 2001 AHJAlexander 2001 AHJ

Post-MI Testing by Age CategoryMedicare

Post-MI Testing by Age CategoryMedicare

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

40 50 60 70 80 90

Age (years)

Pe

rce

nta

ge

Us

e

Cath

PCI

CABG

Invasive Procedure Use by Age

Alexander KA, JACC 2005;46:1479-87. Alexander KA, JACC 2005;46:1479-87.

Predictors of Early Cath in CRUSADEPredictors of Early Cath in CRUSADE

Adjusted Odds RatioAdjusted Odds Ratio

110.50.5 1.51.5 22

Cardiology CareCardiology Care

Age (per 10 yrs)Age (per 10 yrs)

Prior CHFPrior CHF

Renal InsufficiencyRenal Insufficiency

Signs of CHFSigns of CHF

Caucasian RaceCaucasian Race

Female SexFemale Sex

Bhatt et al, JAMA 2004Bhatt et al, JAMA 2004

In-Hospital Mortality by Age and Guidelines Adherence: Observations from CRUSADEIn-Hospital Mortality by Age and Guidelines Adherence: Observations from CRUSADE

3.13.5

5.26.7

8.7

10.4

17.6

0.61

1.82.7

3.5

10.7

6.5

0

2

4

6

8

10

12

14

16

18

20

0 1 2 3 4 5 6Number of Recommended Therapies

Pe

rce

nt

In-h

os

pit

al M

ort

ality

Age >=75 Age <75

- Boden et al, AHA 2005- Boden et al, AHA 2005

Adj. OR:Adj. OR: 0.71 (0.67-0.75)0.71 (0.67-0.75)0.79 (0.75-0.79 (0.75-0.83)0.83)

Age GroupAge Group

The Oldest Old (>90 years) with ACS: Observations From CRUSADE CQI

The Oldest Old (>90 years) with ACS: Observations From CRUSADE CQI

CRUSADE PopulationN: 142,335

CRUSADE PopulationN: 142,335

The Elderly (age >75)N: 46,270 – 33%

The Elderly (age >75)N: 46,270 – 33%

Oldest Old (age >90)N: 5,557 – 4%

Oldest Old (age >90)N: 5,557 – 4%

Death MI Bleeding

7.8% 3.5% 13.1%

12.0% 3.0% 9.9%

Death MI Bleeding

7.8% 3.5% 13.1%

12.0% 3.0% 9.9%

- Skolnick et al, ACC 2006- Skolnick et al, ACC 2006

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

ReasonReason % of Pts% of Pts AgeAge

MedianMedian

Renal Renal FailureFailure

MortalityMortality

In-HospitalIn-Hospital

Pts RefusalPts Refusal 18%18% 8282 26%26% 4.2%4.2%

DNRDNR 16%16% 8585 29%29% 24.6%24.6%

Advanced AgeAdvanced Age 11%11% 9090 22%22% 5.1%5.1%

Active Active BleedingBleeding

4%4% 7777 30%30% 10.4%10.4%

Not Revasc PtNot Revasc Pt 17%17% 7878 35%35% 6.2%6.2%

Co-morbiditiesCo-morbidities 20%20% 7777 42%42% 15.5%15.5%

OtherOther 14%14% 7070 21%21% 5.7%5.7%

Secondary Prevention: It Works at all Ages!

Secondary Prevention: It Works at all Ages!

• Similar benefits of aspirin/beta-blockers: Similar benefits of aspirin/beta-blockers: CCPCCP

• Similar benefits of ace-inhibitors: Similar benefits of ace-inhibitors: HOPEHOPE

• Similar benefits of lipid lowering: Similar benefits of lipid lowering: HPSHPS

• Similar improvements in functional outcomes Similar improvements in functional outcomes with Cardiac Rehab: with Cardiac Rehab: Pasquali 2002 ACCPasquali 2002 ACC

Less Prevention Management Among Elderly Less Prevention Management Among Elderly Out-Patients in REACHOut-Patients in REACH

0102030405060708090

100

% o

f p

ati

en

ts i

n c

ate

go

ry

<65 65-75 76-85 >85

Age categories

≥1 anti-diabetic

≥1 antihypertensive

Use of a statin

≥1 antiplatelet

- Hirsch et al, ACC 2006- Hirsch et al, ACC 2006

Registry/QI• 1100 hospitals• >9 million patient

records• Online data entry tool• Support D2B Alliance

Research and Publications• DCRI analytic center• Over 100 publications

190272

321 362

472547

658

825

1000

0

100

200

300

400

500

600

700

800

900

1000

Fac

ilitie

s

1999 2000 2001 2002 2003 2004 2005 2006 2007F

CathPCI Registry Enrollment

Participants

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Age

<40 40-59 60-79 80

In-Hospital PCI Mortality = 1.22%In-Hospital PCI Mortality = 1.22%

Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26

NCDR : Age and PCI Mortality 2001-2006

n=25,679 n=496,204 n=732,574 n=155,612

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0M

ort

ality

(%

)

Years2001 2002 2003 2004 2005 2006

40-5940 69-79

80

Age

Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26

NCDR Trends : Age and PCI Mortality

Overall PCI Patients= 1.22%Overall PCI Patients= 1.22%

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4M

ort

ality

(%

)

Years2001 2002 2003 2004 2005 2006

Elective PCI PatientsElective PCI Patients

40-5940 69-79

80

Age

Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26

NCDR Trends : Age and PCI Mortality

0

1

2

3

4

5

6

7M

ort

ality

(%

)

Years2001 2002 2003 2004 2005 2006

Urgent/Emergent/Salvage PCI PatientsUrgent/Emergent/Salvage PCI Patients

40-5940 69-79

80

Age

Singh M et.al Circ Cardiovasc Intervent 2009;2:20-26

NCDR Trends : Age and PCI Mortality

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

•

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

0

2

4

6

8

10

12

<50 55 60 65 70 75 80 85 90+

STS NCN VA NY State NNE CCP

Acute Risks: CABG Mortality

Cheitman M, et alAm J Geritri Cards 2001;10:207-223 Cheitman M, et alAm J Geritri Cards 2001;10:207-223

Revascularization in Older Persons with Chronic CADRevascularization in Older Persons with Chronic CAD

Appropriate Use CriteriaAppropriate Use Criteria

J Am Coll Cardiol 2009; 53;530-553

Available at http://www.acc.org

What are Appropriateness Use Criteria?

What are Appropriateness Use Criteria?

• Define “what to do”, “when to do”, and “how often to Define “what to do”, “when to do”, and “how often to do” in the context of local care environments combined do” in the context of local care environments combined with patient and family preferences and valueswith patient and family preferences and values

• Address misuse, overuse and underuseAddress misuse, overuse and underuse• Connected to guideline content Connected to guideline content • Imply a level of detail and complexity that extends Imply a level of detail and complexity that extends

beyond the current recommendationsbeyond the current recommendations

• Define “what to do”, “when to do”, and “how often to Define “what to do”, “when to do”, and “how often to do” in the context of local care environments combined do” in the context of local care environments combined with patient and family preferences and valueswith patient and family preferences and values

• Address misuse, overuse and underuseAddress misuse, overuse and underuse• Connected to guideline content Connected to guideline content • Imply a level of detail and complexity that extends Imply a level of detail and complexity that extends

beyond the current recommendationsbeyond the current recommendations

Appropriateness Use Criteria Appropriateness Use Criteria Modified Rand/Delphi Modified Rand/Delphi

MethodologyMethodology

Appropriateness Use Criteria Appropriateness Use Criteria Modified Rand/Delphi Modified Rand/Delphi

MethodologyMethodology

The WritingCommittee

Define “Appropriateness” for Coronary Revascularization

“ “Coronary revascularization is appropriate when the Coronary revascularization is appropriate when the expected benefits, in terms of survival or health expected benefits, in terms of survival or health outcomes (outcomes (symptoms, functional status, and/or quality symptoms, functional status, and/or quality of lifeof life) exceed the expected negative consequences of ) exceed the expected negative consequences of the procedure”the procedure”

“ “Coronary revascularization is appropriate when the Coronary revascularization is appropriate when the expected benefits, in terms of survival or health expected benefits, in terms of survival or health outcomes (outcomes (symptoms, functional status, and/or quality symptoms, functional status, and/or quality of lifeof life) exceed the expected negative consequences of ) exceed the expected negative consequences of the procedure”the procedure”

Framework for Decision Making Five Core Variables

Framework for Decision Making Five Core Variables

SY

MP

TO

MS

YM

PT

OM

SSST

AB

ILIT

ST

AB

ILIT

YY ISC

HE

MI

ISC

HE

MI

AA

ME

DIC

AL

M

ED

ICA

L

Rx

Rx A

NA

TA

NA

TO

MY

OM

Y

Stable angina

STEMISTEMI

Class IASx

Class IVClass IV

NoneLow risk

HighHighriskrisk

None

MaxMax

No sig.CAD

LM +LM +3v CAD3v CAD A

U

I

Clinical Scenarios – Patients without prior CABGClinical Scenarios – Patients without prior CABG

CTO of 1 v (in the absence of other disease)or 1-2 v disease (no LAD)

Asymptomatic or low risk noninvasive findingsU I=

RevascularizationRevascularization

Shared Decision-makingShared Decision-making

• Collaboration in decision-making between Collaboration in decision-making between physician and patientphysician and patient

• Physician’s role: Communicate information on Physician’s role: Communicate information on harms/benefits of test or treatmentharms/benefits of test or treatment

• Patient’s role: To provide information about Patient’s role: To provide information about values, preferences, lifestyle, beliefs values, preferences, lifestyle, beliefs

• Goal: Treatment decisions are evidence-based Goal: Treatment decisions are evidence-based and are reflective of the patient’s values and and are reflective of the patient’s values and preferences preferences

• Collaboration in decision-making between Collaboration in decision-making between physician and patientphysician and patient

• Physician’s role: Communicate information on Physician’s role: Communicate information on harms/benefits of test or treatmentharms/benefits of test or treatment

• Patient’s role: To provide information about Patient’s role: To provide information about values, preferences, lifestyle, beliefs values, preferences, lifestyle, beliefs

• Goal: Treatment decisions are evidence-based Goal: Treatment decisions are evidence-based and are reflective of the patient’s values and and are reflective of the patient’s values and preferences preferences

Willingness to Consider an Invasive Cardiac Procedure by Age

505560

6570758085

9095

100

45-59 60-69 70-79 80+

CATH PCI CABGAlexander K 2006Alexander K 2006

Importance of Quality of Life versus Importance of Quality of Life versus Quantity of LifeQuantity of Life

“ “ It is with the elderly that some of the contradictions of modern It is with the elderly that some of the contradictions of modern

medicine are cast in clearest relief. medicine are cast in clearest relief.

…….It is a rare older individual who has not accepted his or her .It is a rare older individual who has not accepted his or her

mortality. In this light, the concept of ‘conquering disease’ loses mortality. In this light, the concept of ‘conquering disease’ loses

some of its romance.”some of its romance.”- - James Goodwin MDJames Goodwin MD

Goodwin, JAMA, 1997

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

0

10

20

30

40

50

60

70

80

45-59 60-69 70-79 80+

Lengthen Life Maintain Mental Ability Maintain Independence

Patient CasePatient Case

• Ischemic burden on stress testingIschemic burden on stress testing• Medical therapy optionsMedical therapy options• PCI and CABG optionsPCI and CABG options• Expectation for relief from angina for eachExpectation for relief from angina for each• ““Customized” to patient’s needs and valuesCustomized” to patient’s needs and values

• Ischemic burden on stress testingIschemic burden on stress testing• Medical therapy optionsMedical therapy options• PCI and CABG optionsPCI and CABG options• Expectation for relief from angina for eachExpectation for relief from angina for each• ““Customized” to patient’s needs and valuesCustomized” to patient’s needs and values

85 year old female, small NSTEMI, 3 vessel disease

• Advanced CAD is increasingly a greater challenge in CV Advanced CAD is increasingly a greater challenge in CV medicinemedicine– High morbidity and mortalityHigh morbidity and mortality

• The elderly and those with advanced CAD should receive The elderly and those with advanced CAD should receive evidenced based treatment strategies in ACSevidenced based treatment strategies in ACS– Appropriate medical therapies are underusedAppropriate medical therapies are underused– A targeted invasive approach may be of benefit, if focused on A targeted invasive approach may be of benefit, if focused on

quality of lifequality of life

• A multi-disciplinary approach is required that involves A multi-disciplinary approach is required that involves physical and emotional supportphysical and emotional support

Advanced Coronary Heart Disease: Scope of the Problem in an Aging Population

Advanced Coronary Heart Disease: Scope of the Problem in an Aging Population

ConclusionsConclusions

Evidence-basedTherapies

Evidence-basedTherapies

PersonalizedCare

PersonalizedCare

Evidence-based Guidelines & Patients with Multiple ConditionsEvidence-based Guidelines & Patients with Multiple Conditions

A Balancing Act in Older PersonsA Balancing Act in Older Persons

Evidence-based Guidelines & Patients with Multiple ConditionsEvidence-based Guidelines & Patients with Multiple Conditions

A Balancing Act in Older PersonsA Balancing Act in Older Persons