Geriatric Syndromes in Older Adults Undergoing Cardiovascular Interventions
- The rapidly growing older adult population is frequently affected by a multitude of geriatric- or age-associated conditions that influence cardiovascular outcomes collectively known as, geriatric syndromes.
- Assessment of geriatric syndromes among older adults undergoing cardiovascular interventions using available tools, e.g., Essential Frailty Toolset for physical frailty, is important to inform therapeutic decisions.
- An individualized approach to care that focuses on addressing geriatric syndromes and their interaction with invasive cardiac care is essential to improve patient outcomes and quality of life.
- Further studies on interventions to prevent or reverse geriatric syndromes are needed to decrease morbidity and mortality in the older adult populations.
Coronary angioplasty is approaching its 45th anniversary, beginning in 1977 when Andreas Gruentzig performed the first human angioplasty intraoperatively during bypass surgery1 and later that year performed coronary angioplasty as a primary revascularization procedure. The field has rapidly evolved with the introduction of bare metal stents in 1986 which significantly improved safety and success of percutaneous revascularization procedures.2 This was later followed by the introduction of drug eluting stents in the early 2000's. Simultaneously, the field of interventional cardiology has expanded in the structural domain with the percutaneous closure of patent foramen ovale, atrial, and ventricular septal defects with the first successful human atrial septal defect (ASD) closure in 1975.3 Structural interventions further included percutaneous valve interventions, with the first transcatheter valve implant in 2002 that continued to evolve and improve until present day.
These therapies have specifically increased opportunities of percutaneous treatment for older adults sparing them the more invasive surgical approach. As a consequence of these advances, longevity has increased, and the older adult population has expanded at a rapid pace. In the past few decades, interventional cardiology practice is seeing an ever-larger population of older patients, particularly those above 75 years of age with complex coronary anatomy and structural heart disease pathology. Despite the opportunities for treatment, older patients should be screened for geriatric syndromes including frailty, cognitive impairment, physical dysfunction, and falls, as these conditions can affect therapeutic decisions and impact health outcomes after coronary and structural interventions.
The goal of this review is to provide a succinct approach to evaluation and management of older patients undergoing invasive cardiovascular procedures.
- It is a state of increased vulnerability to stressors due to decreased physiological reserve described over a spectrum from robust (without frailty) to pre-frail and physically frail.4
- Most widely accepted definition was proposed by Fried et al., "a clinical syndrome of increased vulnerability resulting from age associated decline in reserve and function across multiple physiologic systems such as the ability to cope with everyday acute stress is compromised."5
- Fried et al. developed a tool to measure frailty which is based on two large epidemiological studies: The Cardiovascular Health Study and the Women's Health and Ageing Study. It measures frailty as greater than or equal to three abnormal domains of the following: shrinking or weight loss, weakness, poor endurance and energy, slowness, and low physical activity level.5
- However, because it was developed for outpatient practice, it is less practical to use this tool in cardiovascular practice. A simpler and more practical tool using readily available data and simple objective measures was developed by Dr. Jonathan Afilalo and colleagues; the Essential Frailty Toolset was mainly utilized in cardiovascular practice. It uses biomarkers like serum albumin and hemoglobin combined with an assessment of cognitive function using the mini-mental state examination or Mini-Cog© scale and physical function utilizing the chair rise test.6
- Pre-frailty and frailty are independently associated with a higher risk for developing cardiovascular disease (CVD), morbidity, and mortality. As compared to non-frail subjects, pre-frail and frail older patients had a higher incidence of major adverse cardiac events including mortality during a 6-year follow-up period.7
- In the periprocedural period, hospital environment with immobilization, fasting, sleep deprivation and loss of muscle mass and function can rapidly worsen frailty and in turn CVD. CVD can in turn worsen frailty status.
- So what?
- Identification of frailty in older adults undergoing cardiovascular interventions is essential. Interventions to prevent, reverse, or delay onset of frailty may lead to improved cardiovascular outcomes and overall health status after cardiovascular interventions.
- Association with CVD
- Prevalence of cognitive impairment increases with age and CVD further worsens cognitive function.8,9
- Atrial fibrillation was associated with an 87% excess risk of development of dementia when subjects were followed over 15 years, after adjusting for confounders including alcohol consumption, smoking, diet, physical activity, diabetes, hypertension, heart failure, and CVD.8
- In a cross-sectional study, patients with heart failure had a high prevalence of cognitive impairment.9
- Proposed mechanisms include shared risk factors with CVD and dementia which may lead to neurodegeneration, CVD leading to clinical or subclinical strokes causing cognitive impairment, or CVD decreasing cerebral perfusion.10
- Relevance to patient outcomes
- Cognitive impairment can lead to decreased medication adherence11,12
- Increased incidence of delirium in the hospital setting leads to increased hospital length of stay, further cognitive decline, rehospitalization, and death.13
- Screening and its utility
- MiniCog© assessment may identify patients at risk for poor medication adherence or hospital delirium. Utilizing resources to optimize the patient's environment and minimize the risk of medication nonadherence may improve patient outcomes.
- Falls can cause impaired function, morbidity, mortality, and poor quality of life in older persons.
- Many cardiovascular medications including vasoactive medicines and atrioventricular nodal blocking drugs may contribute to falls. These geriatric patients with CVD are frequently prescribed multiple medications as a result of their comorbidities, which can further accentuate the negative effects of some cardiovascular medications, resulting in falls.14
- Falls present with a bleeding risk which results in challenges of weighing risks and benefits to anticoagulation or prolonged antiplatelet therapy in older adults undergoing complex coronary or structural heart disease interventions.
- Fall risk and polypharmacy must be assessed prior to prescribing most cardiovascular medications.
Interventional Cardiology Studies
|PCI for STEMI and Cardiogenic Shock15||111,901 encounters for patients 75 years or older||
|All PCIs16||7,482 octogenarians and 102,236 younger patients||
|PCI for STEMI17||568 patients of which 99 were 75 years or older||
|Outcomes by sex in Acute MI and cardiogenic shock18||134,501 admissions 75 years or older including 69,220 women||
|Guideline-Based Medications after PCI in Japan19||815 participants aged 63 and above divided into "pre-old" group (63-72 years) and "old" group (73 years and above)||
|PCI vs. CABG in unprotected left main CAD20||Meta-analysis of 16 studies with 4,880 patients in patients with mean age greater than 70 years||
|PCI vs. CABG in left main or multivessel CAD21||1,079 adults aged 70 to 89 years||
|Acute MI undergoing surgical, interventional, or medical management22||3,041 patients age 75 years or older||
|Syncope patients with at least 1-vessel obstructive CAD undergoing PCI||9,549 patients age 65 years and older of whom 3,196 underwent PCI||
|CABG vs. PCI and Memory Decline23||1,680 patients age 65 o older||
|PCI in Acute Coronary Syndrome24||6,720,281 patients aged 70 or above||
|Revascularization Strategy in Acute MI and Multivessel Disease25||50,632 patients 65 years or older||
|Frailty in TAVR or SAVR (FRAILTY-AVR Study)6||1,020 patients median age 82 years||
|Bleeding Risk in AVR26||1,195 patients with mean age 81 years||
|Habitual Physical Activity in TAVR27||755 patients with median age of 84 years||
|Sarcopenia in TAVR28||300 patients with mean age 79 years||
|Access Site for TAVR29||728 patients with mean age 84 years||
|Delirium after AVR30||187 patients undergoing SAVR or TAVR||
Approach to Geriatric Syndromes
- Screening to identify geriatric syndromes among older adults undergoing cardiovascular interventions is critical.
- Individualized care plans must be considered to address the patient's primary cardiac conditions in the context of the geriatric syndromes, i.e., falls, cognitive impairment, frailty.14
- Physical, exercise-based interventions like tailored cardiac rehabilitation to prevent or improve frailty has the potential to improve post-procedural outcomes and decrease cardiovascular morbidity and mortality, although more research is needed to confirm its impact.
- Whereas guidelines issued by the National Institutes of Health (NIH) Office of Research on Minority Health in 1994 require the NIH to ensure that women and minorities are included in all NIH-supported human subjects research, recent initiatives have focused on inclusion of older adult populations in research studies. Age cutoffs in clinical trials limit the generalizability of results to a rapidly growing older adult population which represents the majority of patients in cardiovascular practice. A more pragmatic trial that encompasses older patients are needed with a systematic approach to measure geriatric syndromes and their influence of post-procedural outcomes.
Data suggests that older adults are less frequently treated with invasive cardiovascular interventions, like PCI, and guideline directed medical therapy are not fully utilized, as compared to younger adults. Whereas older adults are affected by geriatric syndromes that need to be considered when making therapeutic decisions, data also suggests that interventions, i.e., CABG and PCI in older adults, when indicated, improve mortality and cardiovascular outcomes.
Older patients undergoing cardiovascular interventions should be screened for geriatric syndromes including frailty, cognitive impairment, physical dysfunction, and falls so that individualized therapeutic decisions can be made to address the interaction between cardiovascular therapies and geriatric risks. Data is emerging on optimal interventions that can prevent or reverse geriatric syndromes among older adult populations.
- Mueller RL, Sanborn TA. The history of interventional cardiology: cardiac catheterization, angioplasty, and related interventions. Am Heart J 1995;129:146-72.
- Iqbal J, Gunn J, Serruys PW. Coronary stents: historical development, current status and future directions. Br Med Bull 2013;106:193-211.
- Collado FMS, Poulin MF, Murphy JJ, Jneid H, Kavinsky CJ. Patent foramen ovale closure for stroke prevention and other disorders. J Am Heart Assoc 2018;7:e007146.
- Chen X, Mao G, Leng SX. Frailty syndrome: an overview. Clin Interv Aging 2014;9:433-41.
- Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146-56.
- Afilalo J, Lauck S, Kim DH, et al. Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR study. J Am Coll Cardiol 2017;70:689-700.
- Damluji AA, Chung SE, Xue QL, et al. Frailty and cardiovascular outcomes in the National Health and Aging Trends Study. Eur Heart J 2021;42:3856-65.
- Singh-Manoux A, Fayosse A, Sabia S, et al. Atrial fibrillation as a risk factor for cognitive decline and dementia. Eur Heart J 2017;38:2612-18.
- Albabtain M, Brenner MJ, Nicklas JM, et al. Hyponatremia, cognitive function, and mobility in an outpatient heart failure population. Med Sci Monit 2016;22:4978-85.
- Johansen MC, Langton-Frost N, Gottesman RF. The role of cardiovascular disease in cognitive impairment. Curr Geriatr Rep 2020;9:1-9.
- Gray SL, Mahoney JE, Blough DK. Medication adherence in elderly patients receiving home health services following hospital discharge. Ann Pharmacother 2001;35:539-45.
- Dolansky MA, Hawkins MA, Schaefer JT, et al. Association between poorer cognitive function and reduced objectively monitored medication adherence in patients with heart failure. Circ Heart Fail 2016;9:e002475.
- Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in older persons: advances in diagnosis and treatment. JAMA 2017;318:1161-74.
- O'Neill DE, Forman DE. Cardiovascular care of older adults. BMJ 2021;374:n1593.
- Damluji AA, Bandeen-Roche K, Berkower C, et al. Percutaneous coronary intervention in older patients with ST-segment elevation myocardial infarction and cardiogenic shock. J Am Coll Cardiol 2019;73:1890-1900.
- Batchelor WB, Anstrom KJ, Muhlbaier LH, et al. Contemporary outcome trends in the elderly undergoing percutaneous coronary interventions: results in 7,472 octogenarians. National Cardiovascular Network Collaboration. J Am Coll Cardiol 2000;36:723-30.
- Laghlam D, Diefenbronn M, Varenne O, Picard F. [Demographic evolution, clinical characteristics and in-hospital outcomes of older adults treated by primary angioplasty for ST-segment elevation myocardial infarction]. Ann Cardiol Angeiol (Paris) 2019;68:6-12.
- Vallabhajosyula S, Vallabhajosyula S, Dunlay SM, et al. Sex and gender disparities in the management and outcomes of acute myocardial infarction-cardiogenic shock in older adults. Mayo Clin Proc 2020;95:1916-27.
- Shimada K, Hamada S, Sawano M, et al. Guideline-based medications for older adults discharged after percutaneous coronary intervention in a suburban city of Japan: a cohort study using claims data. Tohoku J Exp Med 2020;252:143-52.
- Khan MR, Kayani WT, Ahmad W, et al. Effect of increasing age on percutaneous coronary intervention vs coronary artery bypass grafting in older adults with unprotected left main coronary artery disease: a meta-analysis and meta-regression. Clin Cardiol 2019;42:1071-78.
- Chang M, Lee CW, Ahn JM, et al. Outcomes of coronary artery bypass graft surgery versus drug-eluting stents in older adults. J Am Geriatr Soc 2017;65:625-30.
- Mori M, Djulbegovic M, Hajduk AM, Holland ML, Krumholz HM, Chaudhry SI. Changes in functional status and health-related quality of life in older adults after surgical, interventional, or medical management of acute myocardial infarction. Semin Thorac Cardiovasc Surg 2021;33:72-81.
- Whitlock EL, Diaz-Ramirez LG, Smith AK, et al. Association of coronary artery bypass grafting vs percutaneous coronary intervention with memory decline in older adults undergoing coronary revascularization. JAMA 2021;325:1955-64.
- Elbadawi A, Elgendy IY, Ha LD, et al. National trends and outcomes of percutaneous coronary intervention in patients >/=70 years of age with acute coronary syndrome (from the National Inpatient Sample Database). Am J Cardiol 2019;123:25-32.
- Wang TY, McCoy LA, Bhatt DL, et al. Multivessel vs culprit-only percutaneous coronary intervention among patients 65 years or older with acute myocardial infarction. Am Heart J 2016;172:9-18.
- Bendayan M, Messas N, Perrault LP, et al. Frailty and bleeding in older adults undergoing TAVR or SAVR: insights from the FRAILTY-AVR Study. JACC Cardiovasc Interv 2020;13:1058-68.
- Sathananthan J, Lauck S, Piazza N, et al. Habitual physical activity in older adults undergoing TAVR: insights from the FRAILTY-AVR Study. JACC Cardiovasc Interv 2019;12:781-89.
- Damluji AA, Rodriguez G, Noel T, et al. Sarcopenia and health-related quality of life in older adults after transcatheter aortic valve replacement. Am Heart J 2020;224:171-81.
- Drudi LM, Ades M, Asgar A, et al. Interaction between frailty and access site in older adults undergoing transcatheter aortic valve replacement. JACC Cardiovasc Interv 2018;11:2185-92.
- Rao A, Shi SM, Afilalo J, et al. Physical performance and risk of postoperative delirium in older adults undergoing aortic valve replacement. Clin Interv Aging 2020;15:1471-79.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention
Keywords: Aged, Frail Elderly, Cross-Sectional Studies, Quality of Life, Drug-Eluting Stents, Platelet Aggregation Inhibitors, Cardiovascular Diseases, Prevalence, Follow-Up Studies, Accidental Falls, Atrial Fibrillation, Foramen Ovale, Patent, Length of Stay, Longevity, Outpatients, Sleep Deprivation, Risk Factors, Risk Assessment, Heart Failure, Cognition, Weight Loss, Heart Septal Defects, Ventricular, Medication Adherence, Cerebrovascular Circulation, Exercise, Anticoagulants, Outcome Assessment, Health Care, Serum Albumin, Hypertension, Angioplasty, Hemoglobins, Biomarkers, Dementia, Delirium, Diabetes Mellitus, Hospitals, Mental Status and Dementia Tests, Pharmaceutical Preparations, Stroke, Cardiac Rehabilitation, Percutaneous Coronary Intervention, National Institutes of Health (U.S.), Coronary Artery Bypass
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