News Release

Use of invasive heart procedures decreases after the age of 75

Peer-Reviewed Publication

Duke University Medical Center

ATLANTA – Duke University Medical Center cardiologists have found that the use of invasive procedures used to clear clogged heart vessels declines as the age of patients increases, with the decrease especially noticeable after the age of 75.

Although the reasons for this decline are unclear, the researchers believe that -- based on their analysis of large clinical trials and their survey of patient preferences -- the key might lie in the complex interaction between patients and their physicians when treatment options are being discussed.

In two poster presentations at the 51st annual scientific sessions of the American College of Cardiology, Duke cardiologist Karen Alexander, M.D., sheds new light on this phenomenon affecting an ever-growing population.

"As the population ages, we are seeing more and more elderly people with symptoms of heart disease, and these patients are safely receiving such invasive procedures as bypass surgery and angioplasty," Alexander said. "Interestingly, the usage of these procedures declines markedly at the age of 75. We don't know why, or whether it is necessarily right or wrong, but the trend is there, clear and strong."

Alexander hopes that the decline is not due to ageism, in which physicians might not want to consider invasive procedures, basing their recommendations solely on a patient's age. One problem physicians face when explaining procedures or new therapies to the elderly is insufficient clinical data, since only 2 percent of all clinical trials enroll patients over the age of 75.

"There is very little data out there for physicians to use when discussing possible procedures with their elderly patients," Alexander said. "Ideally physicians should be able to discuss the potential risks and benefits of any procedure regardless of age, and the elderly patients should be able to fully understand their options."

Alexander first pooled and analyzed the data gathered from two related international trials -- SYMPHONY and Second SYMPHONY (Sibrafabin vs. aspirin to yield maximum protection from ischemic heart events post-acute coronary syndromes). These trials compared the effectiveness of aspirin to a new class of drugs that dissolves blood clots.

Using this database, which included more than 15,000 patients in 35 countries, she examined the rates of invasive procedures among those who were older than 75 and those who were younger. Of these patients, 11.3 percent were 75 or older.

"Compared with younger patients, the elderly tended to be female, with high blood pressures, diabetes and they tended to have had a prior heart attack," Alexander said. "They also had fewer cardiac catheterizations (53 percent vs. 63 percent) and angioplasties (28 percent vs. 37 percent), but had slightly more bypass surgeries (8 percent vs. 7 percent).

"However, when we controlled for all these factors, as well as their risk factors, we still saw this age-related decline, which became more pronounced after age 75," Alexander continued.

One possible explanation, the researchers believe, was that as patients age, they might become less likely to want to risk an invasive procedure. To test this hypothesis, Alexander conducted a patient preference survey of 678 patients admitted to Duke University Hospital for chest pain prior to a referral for cardiac catheterization. Of these patients, 274 (40.4 percent) were at least 75 years old.

The surveys measured patients' willingness to undergo an invasive procedure, as well as their knowledge of the procedures and their risk-tolerance for the potential of dying during bypass surgery. The researchers also collected medical data.

"We found that while patient willingness to consider invasive procedures and accept risks declines with advancing age, the vast majority of elderly patients will still consider these treatments when recommended," Alexander said. "So, it appears that patient preferences are unlikely to explain age-related declines in cardiac procedure use."

Specifically, 82.6 percent of the elderly were willing to consider cardiac catheterization (compared to 91.4 percent for the younger patients). For angioplasty, 70 percent of the elderly were willing to consider the procedures, compared to 86.9 percent for the younger patients. For bypass surgery, 55.2 percent of the elderly were willing to consider the operation, compared to 72.5 percent for the younger patients.

"There is no way around that fact that, in general, patient outcomes get worse as patients age, however, the main question is will they do worse without the treatment," Alexander said. "The key is what happens when the patient and physicians are discussing the patients' medical situation and the available options for treating it.

"We want to make sure that patients who could potentially benefit from these procedures are not being subtly or overtly dissuaded from having these procedures based solely on age," she continued. Alexander is currently designing a study that will determine which specific elderly patients have the most to gain from these procedures. She hopes to be able to find those patients who may be physically "younger" than their chronological age.

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Both of the SYMPHONY trials, from which the elderly data was gleaned, were funded by F. Hoffman-La Roche, Basel, Switzerland. Alexander's patient preference survey was supported by a grant from the Doris Duke Foundation.

Joining Alexander in the patient preference survey were Duke colleagues Tina Harding, Laura Coombs, Ph.D., Katherine Taylor and Eric Peterson, M.D.


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