|Year : 2020 | Volume
| Issue : 3 | Page : 94-101
In-Hospital and 1 year outcomes of octogenarian Indian patients with heart disease: Results from the elder heart registry
Sajan Z Ahmad MD, DM, DNB 1, Cherian Koshy MD, DM 1, George Koshy MD, DM 1, Kiran Jacob MD, DM 2, K Venugopal MD, DM 1
1 Department of Cardiology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
2 Department of Cardiology, Elite Hospital, Thrissur, Kerala, India
|Date of Submission||19-Apr-2020|
|Date of Decision||15-Jun-2020|
|Date of Acceptance||12-Jul-2020|
|Date of Web Publication||26-Sep-2020|
Dr. Sajan Z Ahmad
Department of Cardiology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla - 689 101, Kerala
Source of Support: None, Conflict of Interest: None
Aim: The Elder Heart Registry aims to study the demographics, clinical profile, in-hospital, and 1 year outcomes of octogenarian patients (≥80 years) with acute cardiovascular disease. Materials and Methods: This is a prospective observational, longitudinal cohort, single-center registry of octogenarian cardiac patients admitted to the cardiology intensive care unit (CICU) at a tertiary care teaching hospital in Kerala, India for 2 years. Data analysis was performed using SPSS version 20 software. Results: From a total of 4199 patients admitted to the CICU, the Registry enrolled 406 patients aged ≥80 years, which constituted 9.6% of the total admissions (mean age 84.24 ± 3.67 years, male-to-female ratio of 1.15:1, mean follow-up of 1.2 years). Acute coronary syndromes (ACS) constituted 42.1% of admissions, with ST-elevation myocardial infarction in 22.2%, non-ST elevation myocardial infarction in 64.3%, and unstable angina in 13.4%. Presentation with heart failure (HF) was seen in 36.4% of patients, with HF with preserved ejection fraction (HFpEF) in 51.7%. The rates of in-hospital mortality, mortality on follow-up and rehospitalization were 14.0%, 9.3%, and 21% in the ACS group, and 9.4%, 8.1% and 18.9% in the HF group, respectively (12.1%, 8.6%, and 15.5% in the HF with reduced ejection fraction subset and 10%, 8.3%, and 20% in the HFpEF subset). Atrial fibrillation was the most common arrhythmia (16.5%). Apart from systemic hypertension (77.3%) and diabetes mellitus (53.9%), co-morbidities noted were chronic kidney disease (16.7%), obstructive airway disease (8%), thyroid disorders (4%), significant anemia (3%), depression (2.5%), and malignancy (2%). Conclusions: Octogenarians constitute almost 10% of all admissions to the CICU. ACS and HF are the major cardiac causes for hospitalization among these very elderly patients. The Elder Heart Registry is currently the largest series of octogenarian cardiac patients from India.
Keywords: Acute coronary syndrome, geriatric cardiology, heart failure, octogenarian
|How to cite this article:|
Ahmad SZ, Koshy C, Koshy G, Jacob K, Venugopal K. In-Hospital and 1 year outcomes of octogenarian Indian patients with heart disease: Results from the elder heart registry. J Clin Prev Cardiol 2020;9:94-101
|How to cite this URL:|
Ahmad SZ, Koshy C, Koshy G, Jacob K, Venugopal K. In-Hospital and 1 year outcomes of octogenarian Indian patients with heart disease: Results from the elder heart registry. J Clin Prev Cardiol [serial online] 2020 [cited 2020 Oct 30];9:94-101. Available from: https://www.jcpconline.org/text.asp?2020/9/3/94/296184
| Introduction|| |
The demography and age-structure of patients with cardiovascular disease (CVD) are rapidly undergoing a transformation globally, with an exponential rise in the burden of the elderly population. India is becoming an “aging nation” with 8% of its population being elderly (>60 years old), and this is expected to increase to 12% by 2025., The proportion of the elderly is the highest in the Southern Indian State of Kerala, with the current share of elderly being 12% already, with an expected increase to 20% by 2026. The demographic transition in Kerala is characterized by the highest life expectancy at birth in the country of 74.9 years currently (72 for men and 77.8 for women), as compared to the national average of 69.2 years. This is attributable to the tremendous progress in Kerala's basic health indices, high literacy and educational status, leading to a health-care-seeking behavior, along with advances in the treatment modalities for CVDs, including acute coronary syndrome (ACS), heart failure (HF), and arrhythmias, thereby reducing acute mortality. At the same time, this prolongation of longevity throws up a new challenge in the form of an aging patient population.
The very elderly octogenarian patients (aged 80 years or older) with heart disease belong to a special subset of cardiac patients, with unique characteristics, requiring customized treatment plans with a multidisciplinary team approach. These patients are often excluded from or are underrepresented in most clinical trials. HF and ACS represent major public health problems with a prevalence that increases with advanced age. Despite the high mortality and morbidity in elderly patients with HF and ACS, limited clinical and prognostic data are available in India. The generation of such data would help in the development of appropriate preventive, therapeutic, and rehabilitation strategies for this elderly patient population.
The Elder Heart Registry was designed to study the demographics, clinical profile, treatment, outcomes, and comorbidities in this special population of octogenarians with heart disease and to the best of our knowledge, is currently the largest prospective series of octogenarian cardiac patients from India.
| Materials and Methods|| |
The study was designed as a prospective observational, longitudinal cohort, single-center registry (Elder Heart Registry) of octogenarian cardiac patients (aged 80 years and above) admitted to the cardiology intensive care unit (CICU) of a tertiary care teaching hospital in Kerala, India.
The Elder Heart registry enrolled consecutive admissions of patients aged 80 years and above in the CICU over a period of 2 years, from January 1, 2014 to December 31, 2016. Of the 4199 patients admitted to the CICU over this period, 406 patients (9.7%) were aged 80 years and above and were included in the study. Approval for the study was obtained from the Institutional Research and Ethics Committees. Informed consent was obtained from the patients or caregivers in their family.
Clinical characteristics at presentation, comorbidities, treatment pattern, and in-hospital outcome were studied. A follow-up of the discharged patients was done (clinical follow-up, electronic records, and telephonic interview), and data on rehospitalization and mortality were collected. Follow-up period ranged from 6 months to 2 years, with a mean follow period of 1.2 years.
Data analysis was performed using SPSS version 20 software (SPSS Inc., Chicago, Illinois, USA). Continuous variables with normal distribution were expressed as mean ± standard deviation, and comparisons were done using the Student's t-test. Categorical data were expressed as numbers and percentages, and the comparisons were made using the Chi-square test. Statistical significance was considered as a P < 0.05.
| Results|| |
Demography and clinical profile
A total of 4199 patients were admitted to the CICU of the hospital during the study period. The Elder Heart Registry enrolled 406 patients aged ≥80 years, which constituted 9.67% of the total admissions. The mean age of the cohort was 84.24 (±3.67) years. The male-to-female ratio was 1.15:1. The patient characteristics are summarized in [Table 1].
The most common reasons for admission to the CICU were ACS (42.1%) and HF (36.4%), which together contributed to 78.5% of all the admissions. The other major cardiovascular abnormalities included atrial fibrillation (AF) (16.5%), bradyarrhythmias (15%), high degree atrioventricular (AV) blocks (4.2%), sick sinus syndrome (3.6%), ventricular tachycardia (1.4%), significant mitral regurgitation (27.5%), and aortic stenosis (4.6%). The results are provided with respect to the following aspects: ACS, HF, outcome measures, arrhythmias, valvular heart disease, and comorbidities.
Acute coronary syndrome
About 42.1% of patients (n = 171) presented with an ACS. The mean age of patients who presented with ACS was 84.11 years. The distribution of ACS subsets was as follows: ST elevation myocardial infarction (STEMI) in 22.2% (n = 38), non-ST elevation MI (NSTEMI) in 64.3% (n = 110), and unstable angina (UA) in 13.4% (n = 23). About 70% of these patients presented with chest pain and/or dyspnea. Atypical symptoms were common and seen in almost one-third of the patients (30%). Among the patients who presented with ACS, 62.5% had diabetes mellitus (n = 107), 66% had systemic hypertension (n = 113), 70.8% (n = 121) had history of prior ischemic heart disease, and 20.5% (n = 35) had chronic kidney disease.
Out of the 38 STEMI cases, 23.6% (n = 9) had late presentation (beyond 12 h of index pain), 15.8% (n = 6) were thrombolysed, and 7.8% (n = 3) were taken up for primary PCI. The characteristics and outcomes in the STEMI subgroup compared to the rest of the ACS patients (NSTEMI and UA) are described in [Table 2]. STEMI patients had higher in-hospital mortality (28.9% vs. 10%, P - 0.019).
|Table 2: Comparison between ST elevation myocardial infarction and non-ST elevation myocardial infarction/unstable angina subsets of patients with acute coronary syndrome|
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Overall, 10% (n = 17) of the patients with ACS were taken up for coronary angiography (CAG). Percutaneous coronary intervention (PCI) was done in 41% (n = 7) of these patients. Out of the 17 patients who underwent coronary angiography, 11 had three-vessel disease, 5 had double vessel disease (DVD), and 1 had minor coronary artery disease (CAD). Five patients with severe CAD were given the option of a high-risk coronary artery bypass graft surgery (CABG), but all these patients and their families declined the surgery.
At the time of discharge from the hospital after the index admission, 74.3% (n = 110) were on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. Overall, 95.3% (n = 140) of patients were on clopidogrel. About 4.7% (n = 8) were discharged on oral anticoagulant (OAC) therapy. Of the ACS patients, 51.5% were on beta-blockers, 21% were on angiotensin-converting enzyme inhibitor (ACEI)/angiotensin-receptor blocker (ARB), and 59% of patients were on oral nitrates as antianginal therapy.
About 36.4% (n = 148) of patients presented with features of HF. The mean age of the HF group was 85.1 years. The male-to-female ratio was 1:1. Out of the patients with HF, 56.8% had diabetes mellitus (n = 84), 61.5% had systemic hypertension (n = 91), and 66.9% had prior ischemic heart disease (n = 99). A significant proportion (one-fifth) of HF patients had concomitant chronic kidney disease (CKD in 21.6%, n = 32).
The main etiology for HF hospitalization was ACS, which constituted 54.72% (n = 81). HF with preserved ejection fraction (HFpEF) was seen in 51.8% (n = 77). More than one-fifth (22.3%) of HF patients had AF.
The pattern of drug therapy in patients with HF was as follows: loop diuretics in 78.9%, mineralocorticoid receptor antagonists (MRA) in 48.3%, ACEI/ARB in 33% and beta-blockers in 31.3%. About 55% of patients with HF were on DAPT, and 46.6% were on oral nitrates, either alone or in combination with hydralazine. None of the patients underwent device therapy with an implantable cardiac defibrillator or cardiac resynchronization therapy.
The characteristics and outcome of the two major HF subsets (HFpEF and heart failure with reduced ejection fraction [HFrEF]) are described in [Table 3]. There was no significant difference in in-hospital mortality, rehospitalization, and mortality on follow-up between patients with HFrEF and HFpEF. Ischemic heart disease was the most common cause of HFrEF (74.1%).
|Table 3: Comparison between heart failure with preserved ejection fraction and heart failure with reduced ejection fraction subsets of patients with heart failure|
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The outcomes were assessed based on three parameters. The in-hospital mortality, mortality on follow up and the rehospitalization rates of different patient subsets are summarized in [Table 4].
|Table 4: Mortality and rehospitalization rates of patients in Elder Heart registry|
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The overall in-hospital mortality rate was 9.1% (n = 37). The mean age of patients with in-hospital mortality was 83.35 years. Male-to-female ratio was 0.95. The in-hospital mortality rates were 14.0% for the ACS group and 9.45% for those with HF. The highest in-hospital mortality rate was for those with STEMI (28.9%), with patients with NSTEMI/UA having a lower rate of 10%. There was no difference in the in-hospital mortality rate between HFrEF and HFpEF subsets of HF (12.1% vs. 10%, P 0.775). Among the patients who had in-hospital mortality, 62.2% had diabetes mellitus and hypertension, 51.3% had prior ischemic heart disease, 27.0% had CKD, and 18.9% had AF.
Mortality on follow-up
The overall mortality of patients enrolled in the registry during the mean follow-up 1.2 years was 11.4% (n = 42). The rates were 9.3% for the ACS group, with 7.9% for STEMI patients and 10% for NSTEMI/UA patients. For HF patients, the mortality rate on follow-up was 8.1%, with no difference between HFrEF and HFpEF (8.6% vs. 8.3%, P- 0.972).
The rate of rehospitalization during the mean follow-up 1.2 years was 21% for ACS patients (13.2% for STEMI and 22.3% for NSTEMI/UA). Important predictors for rehospitalization and mortality among ACS patients were diabetes mellitus (65.4%), systemic hypertension (67.3%), significant LV systolic dysfunction (32.7%), and CKD (17.3%). Rehospitalization rate was 18.9% for HF patients, with no difference between HFrEF and HFpEF (15.5% vs. 20%, P- 0.814).
AF was the most common arrhythmia (16.5%, n = 67). About 15% of patients presented with bradyarrhythmia (n = 61). About 4.2% patients had high degree AV block (n = 17) and 3.7% (n = 15) were diagnosed with sick sinus syndrome, with only 6 patients among these 32 (18.8%) undergoing permanent pacemaker implantation. Ventricular tachycardia was seen in 1.4% (n = 6). Almost one-third of the patients had an abnormal rhythm at the time of initial presentation, with sinus rhythm seen only in 69.4% of patients.
Valvular heart disease
Mitral regurgitation (MR) was the most common clinically significant valvular lesion encountered, with 27.5% (n = 28) patients having moderate or severe MR. Degenerative calcific aortic valve disease was the next most common form of VHD. 4.6% (n = 19) of patients had clinically significant (moderate or severe) aortic stenosis (AS) and 3.6% (n = 15) had moderate or severe aortic regurgitation (AR). Isolated AR was seen in only four patients (0.9%). Rheumatic mitral valvular stenosis was seen in two patients (0.4%). Rheumatic multivalvular heart disease (MS + MR + AR) was seen in one patient (0.2%).
Systemic hypertension and diabetes mellitus were present in 77.3% (n = 314) and 53.9% (n = 219) of patients, respectively. There was a high prevalence of chronic kidney disease (CKD) in the study population (16.7%), which was defined as a serum creatinine value of ≥1.5 mg% and/or an e-GFR of ≤60 ml/min/m 2. Obstructive airway disease in the form of chronic obstructive pulmonary disease or asthma was present in 8% (n = 33). Other comorbidities included thyroid disorders (4%), significant anemia defined by a hemoglobin level of <10 g/dl (3%), depression requiring medical treatment (2.5%), and current or past malignancy (2%).
| Discussion|| |
India is in a phase of demographic transition, with the old population itself becoming older. Current statistics for the elderly in India provide a prelude to a new set of medical, social, and economic challenges for the delivery of cardiovascular care to this vulnerable patient population. Health-care planning and resource allocation must consider the implications of an aging population with CVD. The Elder Heart Registry was designed to study the demographics, clinical profile, comorbidities, treatment, and outcomes in the special population of octogenarian patients with heart disease.
Out of the total of 4199 patients admitted to ICU during the study period, 406 patients (9.67% of total) were aged ≥80 years. This age group has been under-represented in most registries and studies, especially from India. The district, in which the Registry was conducted, has currently the highest percentage of people in the age group of 60 years and above (19%) among all the districts in the state. With the projected demographic profile, it is expected that elderly patients with heart disease would increase in the coming years. The median age of the 1,05,388 patients with HF enrolled initially between 2001 and 2004 in the Acute Decompensated Heart Failure National Registry (ADHERE) database was 75 years. The results of the Trivandrum Heart Failure Registry (THFR) from Kerala were initially published in 2015. The mean age of the patients was 61.2 years, and only 4% of patients in the THFR were aged >85 years. The mean age of patients in the Oman Acute Heart Failure Registry of 988 patients was 63 years. On the other hand, >25% of the ADHERE registry patients and >33% of the Japanese ATTEND registry patients were aged over 85 years.
A good proportion (46.5%) of the patients in Elder Heart study belonged to the female sex. This reflects a favorable sex ratio and a lack of gender bias in access to cardiac care in Kerala, with its high rates of female literacy and empowerment. The sex ratio (number of females per thousand males) of Kerala, according to the Census of 2011, is 1084 and the district where the Registry was conducted has the second-highest sex ratio in the state (1132). The proportion of women in the ADHERE registry and the Japanese ATTEND Registry are 52% and 42%, respectively. The THFR population, however, had a lower representation of women (31%).
Coronary artery disease
Of the patients who presented with ACS in the Elder Heart Registry, the most common subset was that of NSTEMI (64.3%), followed by STEMI in 22.2% and UA in 13.4%. In the Kerala ACS Registry of 25748 patients, with a mean age was 60 years, the distribution of ACS type was as follows: STEMI in 37%, NSTEMI in 31%, and UA in 32%. Twenty percent of patients in the Kerala ACS Registry had undergone coronary angiography, and 41% of STEMI patients had received thrombolytic therapy. The overall PCI rate was 12% as against 4% in the Elder Heart group. Out of the 38 STEMI cases in the Elder Heart Registry, 23.6% had late presentation beyond the window period for thrombolytic therapy, and 15.8% were thrombolyzed. The rate of primary PCI in this octogenarian population was 7.8% only. Even though only 10% of all ACS patients underwent coronary angiography (CAG), there was a high rate of PCI (41%) among those who underwent a CAG.
The higher proportion of NSTEMI in the Elder Heart Study could be related to the wider use and positivity of high sensitivity troponin assays, which will categorize more patients into the NSTEMI group. Compared to the Kerala ACS Registry, in which 20% of patients had undergone CAG after an ACS, only 10% of patients underwent CAG in the Elder Heart Registry. The main reason why CAG was not done in the majority of octogenarians was the refusal of consent from patients and/or families due to economic concerns, perceived higher procedural risk and a concept that intervention will be futile in the very elderly. In addition, those patients who were not keen on any form of revascularization were also not advised CAG, so that unnecessary intervention could be avoided.
More than one-third of patients in the Elder Heart Registry presented with HF. HF is a health-care epidemic that extracts a particularly heavy price in the elderly population, with difficulties in diagnosis, frequent undertreatment, recurrent hospitalizations, and a poor prognosis. In real-world clinical practice, multiple comorbidities preclude the optimum use of guideline-based therapy. Among patients with HF in the Elder Heart Registry, CAD was the most common etiology (60.9%). About 42.1% of patients presented with an ACS. In THFR too, with 1205 patients, ischemic heart disease accounted for nearly three-fourths of the HF patients.
In the Elder Heart Registry, 51.7% of patients with HF had HFpEF. This group constituted only one-quarter (26%) of the study population in THFR. This proportion varies from 33% to 50% in the major international registries on HF. Compared to the Elder Heart registry, in THFR, there was a significantly higher 1 year all-cause mortality (30.8%) and rehospitalization (30.2%). In THFR, a higher in-hospital mortality was observed in the HFrEF subset when compared to HFpEF (9.7% vs. 4.8%, P - 0.003). However, in the Elder Heart registry, no such difference between these two HF subsets was found in in-hospital mortality (12.06% vs. 10%, P - 0.775) or rehospitalization (15.5% vs. 20%, P - 0.814). In the Swedish Heart Failure Registry of 8347 patients, the ≥85 year group was characterized by more women, higher systolic blood pressure, lower body-mass index, more than twice as many HF with normal left ventricular ejection fraction, higher incidence of cardiovascular and noncardiovascular comorbidities and less use of proven therapeutics compared with the ≤65-year groups. Data from HF registries will help in identifying high-risk subsets, addressing management challenges, and defining unmet needs in the field of HF. As acute mortality from CAD has come down over the years, the burden of HF related to CAD in the survivors is likely to increase further. In addition, the HFpEF subset will also be on the rise with a higher prevalence of systemic hypertension and diabetes.
In the Kerala ACS registry of 25,748 patients (mean age 60 years), the mortality rate was highest for the STEMI subset (8.2%). The ACS QUIK randomized clinical trial from Kerala showed that, among ACS patients with a mean age of 60.6 years, the 30-day composite event rate was 5.3% (intervention phase) and 6.4% (control phase). In the Cardiological Society of India – Kerala Primary Percutaneous Coronary Intervention (PPCI) Registry, the 1-year mortality rate after STEMI ranged from 3.4% to 8.6% (depending on the PPCI volume). In the Elder Heart Registry, the overall in-hospital mortality rate of octogenarians was 9.1%. It was higher among patients with ACS (14.03%), with the highest mortality rate seen in those with STEMI (28.95%). The follow-up mortality rate was 9.3%.
In the Trivandrum Heart Failure Registry (THFR) of 1205 patients with a mean age of 61.2 years, the in-hospital mortality rate was 8.5%. This was found to be higher in the HFrEF subset when compared to the HFpEF subset. Among patients with HF in the Elder Heart Registry, the in-hospital mortality rate was 9.4%. There was no significant difference between HFrEF and HFpEF (12.1% vs. 10%). This pattern was persisting even in the mortality rate on follow-up (8.6% vs. 8.3%).
Apart from patients with STEMI, the in-hospital mortality rate was not particularly high in the Elder Heart Registry, especially considering the advanced age of the patients and the high prevalence of comorbidities. Optimal and timely management of acute cardiovascular illness, therefore, seems to be effective in limiting acute mortality, even in the very elderly. Ease of access to emergency cardiology services in earlier phases of clinical worsening and better health awareness levels of a literate society could be contributory too. Another reason could be that the Registry included only octogenarians who were admitted to the CICU. Therefore, those patients who were brought dead or who died in the Emergency Department before being able to be shifted to the CICU were excluded. The high mortality of the STEMI subset (28.9%) could be related to the low rates of primary PCI (7.8%) and thrombolysis (15.9%), in addition to the late presentation to the hospital in one-fourth of the patients beyond the ideal time window for reperfusion.
The hearts of the elderly are more prone to arrhythmias due to multiple mechanisms, including remodeling, fibrosis, scarring, altered cytokine milieu, and changes in sodium and calcium currents. There is a higher incidence of degenerative conduction system disease, leading to sick sinus syndrome and AV blocks. The management is complicated by narrow therapeutic window, higher risk of drug interactions due to polypharmacy, poor adherence rates, and the risk of falls, which may cause bleeding complications in patients on anticoagulant therapy. Drugs and device implantations are often underutilized due to various comorbidities. AF is the most common arrhythmia in the elderly and may affect 1 in 10 individuals above the age of 80 years. In the Elder Heart study too, AF was the most common arrhythmia. However, even though AF was seen in 16.5% of patients, oral anticoagulation (OAC) was used only in one-fourth of these patients (4.7%). This underuse of OAC was related to various factors, including denial of consent due to bleeding risk (real and perceived), inability to monitor the International Normalized Ratio regularly, and presence of significant comorbidities precluding optimal anticoagulation. This anticoagulation therapy status is very low when compared to the very high rate (78.2%) seen in the sub-analysis of very elderly patients (>80 years) in the PREFER in AF study, which predominantly utilized Vitamin K antagonists (VKA), with Direct-acting oral anticoagulants (DOAC) used only in 4.5%. VKA were the only form of OAC used in the Elder Heart study too. DOACs were not used in this octogenarian population, mainly due to concerns of cost, bleeding risk, and renal impairment with reduced creatinine clearance. The use of pacemakers was low among the very elderly in the Registry, with less than one-fifth of patients with sick sinus syndrome or high degree AV blocks receiving appropriate therapy. The misconception regarding permanent pacemaker implantation as a major surgical procedure with high mortality and morbidity, coupled with cost considerations, were the major impediments.
Valvular heart disease
Degenerative valve disease is the most common form of valvular heart disease (VHD) in the elderly, with MR and AS being the most prevalent valvular lesions identified in population studies. Nkomo et al. reported results from three large population-based epidemiological studies (Coronary Artery Risk Development in Young Adults, Atherosclerosis risk in Communities, and Cardiovascular Health Study) which included 11,911 patients. In those >75 years of age, the most frequent VHD were MR (9.3%) and AS (2.8%), followed by AR (2%) and MS (0.2%). In the Elder Heart study, a similar pattern was seen in the hospitalized patients too, with significant MR (defined as moderate or severe MR on echocardiography) being seen in more than one-fourth (27.5%) of the patients. A high prevalence of MR was seen in the Registry, with etiologies and clinical effects linked to both CAD and HF. Valvular AS was the next most frequent form of VHD (moderate to severe AS in 4.6%). None of the patients underwent aortic valve replacement (surgical or transcatheter) despite the fact that age is not a contraindication for the management of symptomatic severe AS. Kahraman Ay reported a favorable survival outcome in octogenarian patients undergoing transcatheter aortic valve implantation (TAVI). In future, TAVI would increasingly be considered in this very elderly population and thus provide symptomatic and survival benefits with a lower risk compared to surgical valve replacement.
The pharmacotherapy of octogenarian cardiac patients is fraught with complexities related to polypharmacy, drug interaction, adverse effects, dose adjustments, tolerability, and compliance. Antiplatelet agent use was high in the Elder Heart study population. At the time of discharge, 95.3% of patients were on clopidogrel, and 74.3% were on DAPT. DAPT was exclusively aspirin along with clopidogrel. Statin use was high, with 88% of all patients on either atorvastatin or rosuvastatin. The PALM (Patient and Provider Assessment of Lipid Management) registry had demonstrated statin use of 80.1% for secondary prevention and 62.6% for primary prevention among patients aged >75 years. In the Elder Heart Registry, beta-blockers were used in 51.5%, and 15% of patients were on ivabradine. ACE Inhibitors or ARBs were used in 21%. None of the patients were on therapy with Angiotensin Receptor Neprilysin Inhibitor. MRA were used in 48.3% of patients with HF. Data from meta-analysis of RALES, EMPHASIS-HF, and TOPCAT had pointed toward a need for enhancing MRA use in the elderly. Even though 16.5% of patients had AF, only 4.67% were on OAC therapy. It was observed in the THFR that international treatment guidelines were followed in only one out of every six patients, and those individuals on regular guideline-directed therapy experienced lower mortality and longer survival time. Effort must, therefore, be made to enhance adherence to optimal medical therapy as far as possible, balancing benefits and risks to improve not only the survival but also (and probably more importantly in these very elderly patients) the quality of life (QOL).
Both PCI and CABG surgery are increasingly being done in older patients. In octogenarians with ACS, PCI has been shown to improve survival from all-cause death over 5 years of follow-up. The Bypass Angioplasty Revascularization Investigation trial of patients with multivessel disease included 39% of patients between the ages of 65 and 80 years. None of the patients in the Elder Heart study underwent CABG. Sui et al. have shown that an invasive strategy for non-ST-segment elevation MI improves survival among octogenarians. Therapeutic nihilism related to advanced age per se must not be the reason for denial of the symptomatic and survival benefits of revascularization to octogenarians. However, the higher rates of periprocedural complications and poorer outcomes compared to a younger population must also be given due importance in the decision making process. In octogenarians who present with STEMI, the interventional approach with primary PCI has the potential to bring down acute and in-hospital mortality, along with a lower bleeding risk compared to thrombolytic therapy.
Murad et al. reported on the high prevalence of comorbidities in elderly patients with HF in the Cardiovascular Health Study (mean age 79.2 years). Sixty percent of patients had three or more comorbidities, and only 2.5% had none. Hypertension was the most common comorbidity. The presence of diabetes mellitus, CKD, depression, and functional impairment was associated with higher mortality risk. Saczynski et al. studied the patterns of comorbidity in older patients with HF in the Cardiovascular Research Network PRESERVE Study and found that more than three-fourth of the patients had three or more comorbidities, with a slightly higher burden of comorbidity among patients with HFpEF. In the Elder Heart study too, there was a high prevalence of comorbidities (36.2%), in addition to a high prevalence of systemic hypertension and diabetes mellitus. Conditions such as CKD, lung diseases, and anemia also need to be factored in to individualize evaluation and optimize therapy. Reluctance for pharmacological and/or interventional procedures, including coronary angiography/revascularization, is often linked to the patient's and/or caregiver's perception that comorbidities preclude benefit from optimal guideline-directed management.
Strengths and limitations
To the best of our knowledge, the Elder Heart Registry is the first and largest prospective series focusing on the cardiovascular outcomes of octogenarian cardiac patients in India. However, this is a single center, hospital-based registry which may not truly reflect the cardiac status of octogenarians in the community. Only the patients who were admitted to the cardiac intensive care unit were included in the study; hence, this cohort probably constitutes a “high risk” subset among the heterogeneous group of very elderly heart patients. Since the Registry only enrolled patients aged 80 years and above, there was no comparator group available. Therefore, the results could not be compared with that of the less older patients who were admitted to the Cardiac ICU at the same hospital during the study period.
Future research directions
Multicenter registries and population-based studies will further throw light on the cardiovascular issues and outcomes among the octogenarians. Regional variation and gender differences in outcomes should be analyzed. In addition to the clinical variables, QOL measures, frailty indices, and caregiver burden should also be ideally incorporated in the assessment.
| Conclusion|| |
Octogenarians constitute almost 10% of all admissions to the CICU. ACS and HF are the major cardiac causes for hospitalization among these very elderly patients. The Elder Heart Registry is currently the largest series of octogenarian cardiac patients from India and provides data that could be useful to establish dedicated geriatric cardiology services in the country.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pendyala G, Joshi S, Choudhary S. The ageing nation. Indian J Community Med 2014;39:3-7.
] [Full text]
Situation Analysis of the Elderly in India, Central Statistics Office, Ministry of Statistics and Programme Implementation, Government of India; 2011.
Rajan SI. Aging in Kerala: One more population problem? Asia Pac Popul J 1989;4:19-48.
Economic Review 2018, State Planning Board, Government of Kerala. Available from: https://spb.kerala.gov.in
. [Last accessed on 2020 Jun 15].
Gheorghiade M, Filippatos G. Reassessing treatment of acute heart failure syndromes: The ADHERE registry. Eur Heart J 2005;7:13-9.
Harikrishnan S, Sanjay G, Anees T, Viswanathan S, Vijayaraghavan G, Bahuleyan CG, et al
. Clinical presentation, management, in-hospital and 90-day outcomes of heart failure patients in Trivandrum, Kerala, India: The Trivandrum Heart Failure Registry. Eur J Heart Fail 2015;17:794-800.
Panduranga P, Sulaiman K, Al-Zakwani I, Alazzawi AA, Abraham A, Singh PP, et al
. Demographics, clinical characteristics, management, and outcomes of acute heart failure patients: Observations from the Oman acute heart failure registry. Oman Med J 2016;31:188-95.
Sato N, Kajimoto K, Keida T, Mizuno M, Minami Y, Yumino D, et al
. Clinical features and outcome in hospitalized heart failure in Japan (from the ATTEND Registry). Circ J 2013;77:944-51.
Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al
. Kerala ACS Registry Investigators. Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: Results from the Kerala ACS Registry. Eur Heart J 2013;34:121-9.
Harikrishnan S, Sanjay G, Agarwal A, Kumar NP, Kumar KK, Bahuleyan CG, et al
. One-year mortality outcomes and hospital readmissions of patients admitted with acute heart failure: Data from the Trivandrum Heart Failure Registry in Kerala, India. Am Heart J 2017;189:193-9.
Sanjay G, Jeemon P, Agarwal A, Viswanathan S, Sreedharan M, Vijayaraghavan G, et al
. In-hospital and three-year outcomes of heart failure patients in South India: The Trivandrum Heart Failure Registry. J Card Fail 2018;24:842-8.
Holmström A, Sigurjonsdottir R, Edner M, Jonsson A, Dahlström U, Fu ML. Increased comorbidities in heart failure patients ≥ 85 years but declined from & gt; 90 years: Data from the Swedish Heart Failure Registry. Int J Cardiol 2013;167:2747-52.
Savarese G, Vasko P, Jonsson Š, Edner M, Dahlström U, Lund LH. The Swedish Heart Failure Registry: A living, ongoing quality assurance and research in heart failure. Ups J Med Sci 2019;124:65-9.
Huffman MD, Mohanan PP, Devarajan R, Baldridge AS, Kondal D, Zhao L, et al
. Effect of a quality improvement intervention on clinical outcomes in patients in India with acute myocardial infarction: The ACS QUIK randomized clinical trial. JAMA 2018;319:567-78.
Jabir A, Mathew A, Zheng Y, Westerhout C, Viswanathan S, Sebastian P, et al
. Procedural volume and outcomes after primary percutaneous coronary intervention for ST segment elevation myocardial infarction in Kerala, India: Results of the Cardiological Society of India – Kerala Primary Percutaneous Coronary Intervention Registry. J Am Heart Assoc 2020;9:E014968.
Curtis AB, Karki R, Hattoum A, Sharma UC. Arrhythmias in patients ≥80 years of age: Pathophysiology, management, and outcomes. J Am Coll Cardiol 2018;71:2041-57.
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al
. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001;285:2370-5.
Hanon O, Vidal JS, Le Heuzey JY, Kirchhof P, De Caterina R, Schmitt J, et al
. Oral anticoagulant use in octogenarian European patients with atrial fibrillation: A subanalysis of PREFER in AF. Int J Cardiol 2017;232:98-104.
Kodali SK, Velagapudi P, Hahn RT, Abbott D, Leon MB. Valvular heart disease in patients ≥80 years of age. J Am Coll Cardiol 2018;71:2058-72.
Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: A population-based study. Lancet 2006;368:1005-11.
Kahraman Ay N. Impact of age on long term survival following transcatheter aortic valve implantation. J Geriatr Cardiol 2019;16:265-71.
Nanna MG, Navar AM, Wang TY, Mi X, Virani SS, Louie MJ, et al
. Statin use and adverse effects among adults >75 years of age: Insights from the patient and provider assessment of lipid management (PALM) registry. J Am Heart Assoc 2018;7:10.
Ferreira JP, Rossello X, Eschalier R, McMurray J, Pocock S, Girerd N, et al
. MRAs in elderly HF patients – Individual patient data metaanalysis of RALES, EMPHASIS-HF, and TOPCAT. JACC Heart Fail 2019;7:1012-21.
Barywani SB, Li S, Lindh M, Ekelund J, Petzold M, Albertsson P, et al
. Acute coronary syndrome in octogenarians: Association between percutaneous coronary intervention and long-term mortality. Clin Interv Aging 2015;10:1547-53.
BARI Investigators. The final 10-year follow-up results from the BARI randomized trial. J Am Coll Cardiol 2007;49:1600-6.
Sui YG, Teng SY, Qian J, Wu Y, Dou KF, Tang YD, et al
. Invasive versus conservative strategy in consecutive patients aged 80 years or older with non-ST-segment elevation myocardial infarction: A retrospective study in China. J Geriatr Cardiol 2019;16:741-8.
Cai JX, Yap J, Gao F, Koh TH, Tong KL, Ong HY, et al
. Elderly Asian patients have lower revascularisation rates and poorer outcomes for ST-elevation myocardial infarction compared to younger patients. Ann Acad Med Singapore 2020;49:3-14.
Franken M, Nussbacher A, Liberman A, Wajngarten M. ST elevation myocardial infarction in the elderly. J Geriatr Cardiol 2012;9:108-14.
Murad K, Goff DC Jr, Morgan TM, Burke GL, Bartz TM, Kizer JR, et al
. Burden of comorbidities and functional and cognitive impairments in elderly patients at the initial diagnosis of heart failure and their impact on total mortality: The cardiovascular health study. JACC Heart Fail 2015;3:542-50.
Saczynski JS, Go AS, Magid DJ, Smith DH, McManus DD, Allen L, et al
. Patterns of comorbidity in older adults with heart failure: The Cardiovascular Research Network PRESERVE study. J Am Geriatr Soc 2013;61:26-33.
[Table 1], [Table 2], [Table 3], [Table 4]