August 11, 2017
By Marilynn Larkin
NEW YORK (Reuters Health) – Comparing an invasive with a conservative approach to acute coronary syndrome (ACS) management in patients over 80 revealed only “minor differences” in health-related quality of life (HRQOL), researchers in Norway say.
In patients with ACS, an invasive approach improves survival and reduces complications compared with conservative management, and current guidelines recommend evaluation for invasive management after medical stabilization. However, those recommendations are based mainly on younger patients, according to Dr. Bjorn Bendz of Oslo University Hospital and colleagues.
To compare the two management strategies in patients over age 80 with non-ST-elevation myocardial infarction and unstable angina, the team randomized 229 to early coronary angiography - with immediate evaluation for percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or optimal medical therapy - and 228 to a conservative strategy (optimal medical therapy alone).
The groups were similar in age and gender makeup (mean age 84; about 46% female), and in their medical history, including prior cardiac procedures.
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The Short Form 36 health survey (SF-36), used to assess HRQOL at baseline and at one-year follow-up, measures eight health domains: physical functioning, role limitations due to physical problems, bodily pain, general health perception, vitality, social functioning, role limitations due to emotional problems, and mental health.
As reported online July 13 in Age and Ageing, more than 90% of both groups completed the SF-36 at baseline, and about 60% completed it at follow-up.
Compared with the conservative strategy, the invasive approach reduced incidence of the composite endpoint of myocardial infarction, need for urgent revascularization, stroke, and death - without increasing bleeding complications.
However, the two groups did not differ significantly in changes in HRQOL scores from baseline to follow-up, except for a small but statistically significant difference in bodily pain that the authors noted “may not necessarily be clinically significant.”
Dr. Bendz told Reuters Health by email that it is easier to measure hard endpoints such as stroke and death than HRQOL, “which is influenced by multiple factors, such as personality, culture, age, sex, religion, expectations and coping (ability).”
“SF-36 may not be the most sensitive and reliable tool for measuring heart-related HRQOL in the very elderly with acute coronary syndromes,” he said. “However, more disease-specific questionnaires have not been validated in these very old patients.”
Dr. Robert Greenfield, Medical Director of Non-Invasive Cardiology and Cardiac Rehabilitation at Orange Coast Memorial Medical Center in Fountain Valley, California, commented, “This is a good study, as it raises many issues becoming more pertinent in our aging population with the availability of advanced technology. . . and attempts to evaluate what is best for the patient over 80.”
“Certainly, when intervening invasively on an older individual, the risks of the procedure may be greater, considering their response to sedation, contrast load impacting reduced kidney function, the multiple comorbidities that may accompany old age, and their frailty index in general,” he told Reuters Health by email.
“On the other hand,” he noted, “there are a significant number of patients over 80 who are active, vigorous, and still may be working.”
“A decision about how aggressive to be should be made on a patient-by-patient basis, and not necessarily based on ‘guidelines’ developed in randomized-controlled studies with careful patient selection and exclusion,” he continued. “A good policy might be to assess each patient based on their personal medical status, their desire to achieve the best quality of life, the skill of the cardiologist performing the procedure, and the support system available to the patient upon discharge, as well as other factors.”
“The physician’s role is to exercise ‘good judgment’ in safeguarding the patient, as well as respecting his or her wants and needs with sincerity, honesty, and compassion,” Dr. Greenfield concluded.
Age Ageing 2017.
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