Octogenarians en cardiologie Jan Paul Ottervanger, Isala, Zwolle - - PowerPoint PPT Presentation

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Jan Paul Ottervanger, Isala, Zwolle 31ste WCN Congres 29-30 november 2018

Octogenarians en cardiologie

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Disclosures

(potentiële) belangenverstrengeling Geen Voor bijeenkomst mogelijk relevante relaties met bedrijven Bedrijfsnamen

• Sponsoring of onderzoeksgeld
• Honorarium of andere (financiële)

vergoeding

• Aandeelhouder
• Andere relatie, namelijk …

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Cardiologie bij/voor ouderen: Wie is oud?

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Renzulli KR, Times, June 13, 2017 21-37 years 37-52 years 53-72 years > 73 years

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Wie is oud?

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ASPREE trial, N Engl J Med 2018,379:1519-28

Persons in Australia and the United States who were 70 years of age or older (or ≥65 years of age among blacks and Hispanics in US)

Healthy Elderly: Russia: > 60? Africa: > 55?

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Nieuwe titel:

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Iedereen 120: De cardiologie is er (bijna) klaar voor, WCN 2018

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Waarom 120?

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X Dong, B. Miholland & J. Vijg Nature 538, 257-259 (2016)

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Levensverwachting sinds 1900

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1 3 O c t o b e r 2 0 1 6 | VO L 5 3 8 | N AT U RE | 2 5 7

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Levensverwachting bij 80+ in NL

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Maximale levensverwachting

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SCIENCE VOL 296 10 MAY 2002

• Eerdere voorspellingen van maximum steeds verkeerd
• Stijging max levensverwachting voorspelbaar:

1 jaar/4 jaar

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Ontwikkelingen in de cardiologie

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Ziektebeeld Preventie Behandeling

• 1. Ischemische hartziekten

✔ ✔

• 2. Ritmestoornissen

✔ ✔

• 3. Kleppen

✔ ✔

• 4. Hartfalen

✔ ✔

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Ontwikkelingen in de cardiologie

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Ziektebeeld Preventie Behandeling

• 1. Ischemische hartziekten

✔ ✔

• 2. Ritmestoornissen

✔ ✔

• 3. Kleppen

✔ ✔

• 4. Hartfalen

✔ ✔

Maar geldt dat ook voor ouderen????

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Statins for Secondary Prevention in Elderly Patients

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Results of HYVET (age > 80, BP > 160)

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Sprint Trial, intensive vs standard, 28% >75

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N Engl J Med 2015;373:2103-6

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Invasive treatment of MI (non-STEMI)

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Karen P. Alexander et al. Circulation. 2007;115:2549-2569

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Treatment of STEMI in the elderly

J Am Coll Cardiol Intv 2010;3:324 –31

More benefit of primary PCI with increasing age

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Stroke prevention by warfarin

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Prevented strokes / 1000 / yr 12 6 >75 <75 SPAF II, Lancet 1994;343:687-691 10

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We can induce regression of atherosclerosis

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2017:376;14

and after 4 years medical treatment Stable angina, before …

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Sterfte aan hart- en vaatziekten neemt af (NL)

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STERFTE 1996 2015 2016 Mannen Kanker 21244 24692 25350 H&V 25208 18567 18148 Vrouwen Kanker 17027 21098 21626 H&V 26105 20812 20499

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Effecten biventriculaire pacemaker

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Effects of hypertension treatment on dementia

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• 1. Sterfte aan hart- en vaatziekten nog steeds hoog

STERFTE 1996 2015 2016 Mannen Kanker 21244 24692 25350 H&V 25208 18567 18148 Vrouwen Kanker 17027 21098 21626 H&V 26105 20812 20499

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Verwachte ziektelast: 2012

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Verwachte ziektelast: 2030

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• 2. Limited public awareness
• Almost never too late to change prognosis
• Knowing ≠ doing

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Easy ways to shorten your life…

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• Don’t check your blood pressure, cholesterol or glucose
• Continue smoking
• Pack on the pounds
• Avoid exercise
• Make bad dietary choices

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Example: Only one in three men and only one in four women over age 80 have their blood pressure under control Reasons for undertreatment:

• Higher potential for adverse effects, changing balance benefits and risks
• Less evidence
• Fear for overtreatment of vulnerable elderly
• Polypharmacy and cognitive decline
• Lower net benefits of intervention due to competing risk from multiple other comorbidities
• Shifting clinical priorities and patient preference.
• 3. Elderly less (well) treated: undertreatment

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• 3. Elderly less (well) treated: overtreatment

Hambling, et al, Diab Med 2017;23:1219-27

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• 4. Less evidence based medicine in elderly

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• 4. Less evidence based medicine in elderly

First, heterogeneity of older patients may lead to overtreatment of vulnerable and undertreatment of fit older patients. Second, representative older patients are underrepresented in clinical studies and endpoints studied may not reflect the specific needs of older patients. Third, adequate clinical tools and schooling are lacking to aid physicians in clinical decision-making. Neth J Med. 2015 Jun;73(5):211-8

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• 5. Limited experience with Shared Decision Making

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Evidence for Shared Decision Making

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• Increased overall patient satisfaction
• Reduced costs: Elective surgery, BPH surgery, PSA screening, end-of-life

care

• Studies that looked at behavioral measures (reaching a decision;

adherence) showed positive results in 37 percent of the cases

• Studies of self-reported symptoms (e.g., QOL, mental function, etc.) were

42 percent positive

• No negative results were found

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Why no Shared Decision Making?

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Why no Shared Decision Making?

• No time
• Performing procedures important
• Guidelines based treatment important
• Not trained to do it
• Are we paid for that?

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Vanwege tijd niet benoemde uitdagingen

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• 1. Polyfarmacie
• 2. Kennis over heterogeniteit
• 3. Samenwerking verschillende disciplines (!)
• 4. Meer onderzoek naar wat ouderen zelf willen

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Take home messages

1. Hoge leeftijd vaker “normaal”, ook > 100 2. Ook hoge leeftijd steeds betere levensverwachting 3. In cardiologie veel mogelijkheden, ook op hogere leeftijd 4. Zowel kwantiteit als kwaliteit van leven 5. Hart- en vaatziekten de komende decennia nog steeds hoge incidentie en prevalentie 6. Bewustwording bij populatie/ patienten /gezondheidswerkers dat

• ok ouderen prognose kunnen veranderen

7. Bewustwording over- en onderhandeling 8. De “evidence based medicine” bij ouderen meer ontwikkelen 9. Gezamenlijke besluitvorming (patiënt, familie, verschillende gezondheidswerkers) bevorderen