Towards a Comprehensive Assessment of the Geriatric Population With AS, Part II: Non-Cardiac Conditions

Editor's Note: This is Part II of a two-part Expert Analysis. Go to Part I.

Assessment of Common Non-Cardiac Conditions Interacting With AS: Summary Table

 

Associated With Age

Associated With Reduced Life Expectancy

Increases the Progression of AS

Associated With Poor Procedural Outcomes

Modifiable

Medical

 

 

 

 

 

Chronic Kidney Disease1,2,3

+

+

+

+

-

Paget's Disease of the Bone4,5

+

+/-

+

-

+

Osteoporosis6,7

+

+/-

+

-

+

COPD8,9

+/-

+/-

-

+

+/-

Malignancy

+/-

+/-

+/-

-

+/-

Malnutrition10,11,12

+/-

+/-

-

+

+

Integrated Syndromes

 

 

 

 

 

Heyde's Syndrome13

+/-

+/-

-

+

+

Frailty14

+

+

-

+

+/-

Neurocognitive

 

 

 

 

 

Dementia15

+

+

-

+

+/-

Depression16,17

+/-

+

-

+

+

Psychosocial

 

 

 

 

 

Ageism18,19,20

+

+

-

+

+

[+ = yes          +/- = possibly yes, depending on the situation          - = no]
Cardiologists and other members of the heart team assessing geriatric patients with AS need to be cognizant of non-cardiac conditions that their patients have that affect management decisions. The table above provides a summary of common non-cardiac conditions that may affect older adults with AS. These medical conditions, syndromes, neurocognitive conditions, and psychosocial barriers to care are important to recognize because of their impact on both progression of AS and post-procedural outcomes. In addition, the modifiability of some of the conditions point to potential factors that can be targeted to reduce AS progression and/or improve post-procedural outcomes.
AS = aortic stenosis; COPD = chronic obstructive pulmonary disease.

In addition to cardiac issues, assessment of the geriatric patient with aortic stenosis (AS) should include an evaluation of issues related to poor procedural outcomes and conditions that may limit life expectancy. The three main conditions associated with age and the calcific pathogenesis of AS are chronic kidney disease (CKD), Paget's disease of the bone, and osteoporosis. CKD plays a role in pathogenesis independent of traditional atherosclerotic risk factors because of the presence of uremia and derangements of calcium metabolism seen in these patients. The rates of progression of AS are accelerated in patients with end-stage renal disease (ESRD), 0.23 cm2 per year, as compared to the population without kidney disease (0.05–0.1 cm2 per year).1 An increased rate of progression has also been shown in patients with earlier stages of CKD;2 surgical aortic valve replacement (SAVR) can also produce a further decrease in renal function, which is associated with worsened overall outcomes.3 AS is a disease that is linked to the pathophysiology of bone metabolism, and mature lamellar bone has been found in pathologic examination of diseased valves at the time of AVR.6 Two common diseases of bone in the elderly, osteoporosis and Paget's disease (associated with bone pain and hearing loss), are both linked to the development and accelerated progression of AS via alterations in calcium metabolism.4,5,7 Asymptomatic AS patients with these comorbidities should be followed closely for rapid progression.

Other conditions that may be present in an elderly patient, such as chronic obstructive pulmonary disease (COPD), malignancy, and malnutrition, are more loosely associated with age and their effects on life expectancy vary according to disease severity. The presence of COPD at the time of SAVR may result in prolonged ventilatory support and its associated complications, including increased mortality.8,9 Radiation treatments needed to treat certain malignancies can also accelerate the progression of valvular disease. Malnutrition is a condition to which the geriatric population is particularly susceptible because of factors such as loss of gustatory sense, early satiety, poor dentition, lack of transportation to obtain a variety of foods, and lack of the social aspect of mealtime.10 Preoperative malnutrition has been linked to increased in-hospital mortality and morbidity with longer vasopressor requirements, length of stay, and infection-related complications.11,12

Assessment of Integrated Clinical Syndromes

A comprehensive evaluation of the geriatric patient with AS also involves the integration of clinical information. An important syndrome involving AS in the geriatric patient is Heyde's syndrome consisting of the constellation of AS, the acquired coagulopathy of von Willebrand syndrome type 2A, and gastrointestinal (GI) bleeding of unknown etiology or confirmed to be related to the presence of intestinal angiodysplasia. The bleeding associated with Heyde's syndrome is difficult to definitively treat with endoscopy and cauterization due to a high rate of recurrence. AVR, while carrying the risk of periprocedural bleeding, reduces the shear stress-related proteolysis and coagulopathy, and has been shown to be curative for GI bleeding associated with angiodysplasia.13 Another way to integrate the clinical information of an elderly patient with AS is to assess for frailty, an important topic in geriatric medicine linked to poor procedural and general outcomes.14

Assessment of Neurocognitive Disorders

Neurocognitive disorders, such as dementia and depression, can exert an influence on decision making and outcomes in geriatric patients with AS. Dementia is more common in older adults, and awareness about this condition prior to a planned procedure is useful because preventative behavioral modifications can be effective in reducing postoperative complications.15 Evaluation for geriatric depression is also useful for the implementation of preventative strategies. Untreated disease has been shown to diminish the functional benefits of open heart surgery.16 In a cyclical fashion, the presence of heart disease also affects the treatment of geriatric depression and is associated with difficulty in obtaining the goal of remission.17 Screening for depression during a review of systems is important to assess and address potential barriers to achieving health benefits from SAVR and TAVR, as well as serve as an opportunity for the elderly patient to voice mental health concerns and be directed to appropriate psychiatric care.

Assessment of the Psychosocial Context of Health Care Delivery

Elderly patients, despite Medicare, may still have financial concerns related to their medical care. In addition, they face ageism that can result in an inappropriate loss of autonomy in decision making and manifest as prejudice as a result of applying stereotypes and generalizations rather than assessing them on an individual basis. In 2003, the Alliance for Aging Research examined how ageism affects the health care of older adults. Among the findings, they found that effective interventions and treatments are underutilized in the elderly and older adults are excluded from most clinical trials.18 There is evidence that there are elderly patients who may benefit from AVR but are not offered it as an option because of age alone, not specifically related to comorbidities.19,20 While these issues seem different because they originate from outside of the patient, they nevertheless can have the same impact as medical/psychiatric conditions resulting in prolonged suffering, loss of independence, and premature death.18 The health care systems with which elderly patients interact must also be assessed to ensure that clinicians receive training in geriatrics, care is free of ageist bias, and effective treatment options are offered to appropriate patients.

Conclusion: Assessment of Patients Using a Heart Team Approach

In recognition of the complexity of decision making in valvular disease, it is recommended that a heart team consisting of a primary clinical cardiologist, imaging specialist, interventional cardiologist, anesthesiologist, and cardiothoracic surgeon is employed to analyze each case.21 The primary heart team, especially in the case of an elderly patient with multiple comorbidities, may need to be expanded to include other providers (e.g., geriatrician or geriatric cardiologist) depending on the particular needs of each patient. Shared decision making is especially useful when multiple treatment modalities are available, and patients benefit from having their concerns addressed from various angles.

References

  1. Ureña P, Malergue MC, Goldfarb B. Evolutive aortic stenosis in HD patients: analysis of risk factors. Nephrologie 1999;20:217-25.
  2. Masuda C, Dohi K, Sakurai Y, et al. Impact of chronic kidney disease on the presence and severity of aortic stenosis in patients at high risk for coronary artery disease. Cardiovasc Ultrasound 2011;9:31.
  3. Bove T, Calabrò MG, Landoni G, et al. The incidence and risk of acute renal failure after cardiac surgery. J Cardiothorac Vasc Anesth 2004;18:442-5.
  4. Strickberger SA, Schulman SP, Hutchins GM. Association of Paget's disease of bone with calcific aortic valve disease. Am J Med 1987;82:953-6.
  5. Altman RD, Bloch DA, Hochberg MC, et al. Prevalence of pelvic Paget's disease of bone in the United States. J Bone Miner Res 2000;15:461-5.
  6. Mohler ER 3rd, Gannon F, Reynolds C, et al. Bone formation and inflammation in cardiac valves. Circulation 2001;103:1522–1528.
  7. Aksoy Y, Yagmu, C, Tekin GO, et al. Aortic valve calcification: association with bone mineral density and cardiovascular risk factors. Coron Artery Dis 2005;16:379-83.
  8. Chopard R, Meneveau N, Chocron S, et al. Impact of chronic obstructive pulmonary disease on Valve Academic Research Consortium-defined outcomes after transcatheter aortic valve implantation (from the FRANCE 2 Registry). Am J Cardiol 2014;113:1543-9.
  9. Spoon DB, Orszulak TA, Edell ES, et al. Risk of aortic valve replacement in patients with aortic stenosis and chronic obstructive pulmonary disease. J Heart Valve Dis 2012;21:314-9.
  10. Furman ET. Undernutrition in older adults across the continuum of care: nutritional assessment, barriers, and interventions. J Gerontol Nurs 2006;32:22-7.
  11. Chermesh I, Hajos J, Mashiach T, et al. Malnutrition in cardiac surgery: food for thought. Eur J Prev Cardiol 2014;21:475-83.
  12. Lomivorotov VV, Efremov SM, Boboshko VA, et al. Prognostic value of nutritional screening tools for patients scheduled for cardiac surgery. Interact Cardiovasc Thorac Surg 2013;16:612-8.
  13. Vincentelli A, Susen S, Le Tourneau T, et al. Acquired von Willebrand syndrome in aortic stenosis. N Engl J Med 2003;349:343-9.
  14. Forman, DE, Rich MW, Alexander KP, et al. Cardiac care for older adults: time for a new paradigm. J Am Coll Cardiol 2011;57:1801-10.
  15. Inouye SK, Bogardus ST, Charpentier PA, et al. A mutlicompartment intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.
  16. Mallik S, Krumholz HM, Lin ZQ, et al. Patients with depressive symptoms have lower health status benefits after coronary artery bypass surgery. Circulation 2005;111:271-7.
  17. Alexopoulos GS, Kiosses DN, Murphy C, et al. Executive dysfunction, heart disease burden, and remission of geriatric depression. Neuropsychopharmacology 2004;29:2278-84.
  18. Alliance for Aging Research. Ageism: How Healthcare Fails the Elderly. Washington, DC: Alliance for Aging Research; 2003.
  19. Lung B, Cachier A, Baron G, et al. Decision-making in elderly patients with severe aortic stenosis: Why are so many denied surgery? Eur Heart J 2005;26:2714-20.
  20. Charlson E, Legedza ATR, Hamel MB. Decision-making and outcomes in severe symptomatic aortic stenosis. J Heart Valve Dis 2006;15:312-21.
  21. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57-e185.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Sleep Apnea

Keywords: Aged, Ageism, Angiodysplasia, Aortic Valve, Aortic Valve Stenosis, Calcium, Cardiac Surgical Procedures, Comorbidity, Decision Making, Dementia, Dentition, Depression, Endoscopy, Geriatrics, Hearing Loss, Heart Diseases, Hospital Mortality, Kidney Failure, Chronic, Length of Stay, Life Expectancy, Malnutrition, Medicare, Mental Health, Mortality, Premature, Osteoporosis, Pain, Proteolysis, Pulmonary Disease, Chronic Obstructive, Renal Insufficiency, Chronic, Risk Factors, Surgeons, Syndrome, Uremia


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