Interventional cardiology

5 lessons on cardiac surgery in the elderly

Interventional cardiologist Dr Brahmajee Nallamothu from the Ann Arbor VA Medical Center in Michigan gave delegates five points to contemplate when considering elderly patients for cardiac surgery.

Addressing the conference during a clinical session on revascularisation therapies –  optimising patient care Dr  Nallamothu stressed that it was really important to keep in mind that perspectives change over time.

“If I gave this talk 20 years ago when I was just starting off as a house officer my perspective about age and its relationship to procedures would have been different,” he told delegates.

Dr Nallamothu’s top 5 take home lessons:

#1 People and populations aren’t getting younger… this means cardiovascular disease is a growing issue for the elderly

Cardiovascular disease is the number one cause of death in the elderly and is associated with a broad range of conditions such as coronary artery disease, stroke, valvular heart disease, congestive heart failure and arrhythmias. Dr Nallamothu conceded that he was stating the obvious, but said it was really important for framing how we think about the therapies that we deliver.

#2 Surgical advances don’t happen in isolation…

Dr Nallamothu noted there had been many advances in cardiac surgery, for instance: LIMA is commonly used in most elderly patients with cardiac surgery; off-pump CABG has potential benefits with stroke and cognitive function; newer prosthetic and bio-prosthetic valves with physiologically better haemodynamics; cardio-protection and anaesthesia safety; better rehabilitation and recovery.

However, he said that while this was undoubtedly good news, it had resulted in a ‘Clinician’s Paradox’ where cardiac surgery was safer in the elderly than any time in history but decisions were tougher for physicians and patients due to the better options.

#3 Chronological age is secondary to physiological age…

Dr Nallamothu told delegates that assessing the frailty of a patient, rather than age, might be more appropriate but it was tough to assess and apply in clinical practice. Many tools for measuring frailty existed but there was no consistent measurement. “It’s difficult to top the ‘eyeball’ test… more work is urgently needed,” he said.

#4 High-risks and high-rewards

The TIME trial of invasive versus medical therapy in elderly patients aged 75 or older found that at six months, angina and MACE were significantly lower in the revascularized patients.

#5 Shared decision-making – finding the sweet spot

According to Dr Nallamothu this was an important and critical discussion to have with patients and their families.

It was about balancing the families’ goals and preferences with critical evidence and expertise, as well as the biological, psychological and sociological context of the conversation that is happening and the types of therapies patients are considering, he said.

“It’s that sweet spot of shared decision-making that tries to incorporate all those things – that’s a very difficult thing to do. “

“As I get older I realise that one of the most important roles that we have as physicians is to help people along the path,” he said.

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