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	+	+	-	+	+

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

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18. Alliance for Aging Research. Ageism: How Healthcare Fails the Elderly. Washington, DC: Alliance for Aging Research; 2003.
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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.

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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