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

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

Disclosures (potentiële) belangenverstrengeling Geen Voor bijeenkomst mogelijk relevante relaties Bedrijfsnamen met bedrijven • Sponsoring of onderzoeksgeld - • Honorarium of andere (financiële) - vergoeding • Aandeelhouder - • Andere relatie, namelijk … - Isala

Cardiologie bij/voor ouderen: Wie is oud? 21-37 years 37-52 years 53-72 years > 73 years Renzulli KR, Times, June 13, 2017 Isala 3

Wie is oud? Healthy Elderly: 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) ASPREE trial, N Engl J Med 2018,379:1519-28 Russia: > 60? Africa: > 55? Isala 4

Nieuwe titel: Iedereen 120: De cardiologie is er (bijna) klaar voor, WCN 2018 Isala 5

Waarom 120? X Dong, B. Miholland & J. Vijg Nature 538 , 257-259 (2016) Isala 6

Levensverwachting sinds 1900 Isala 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 7

Levensverwachting bij 80+ in NL Isala 8

Maximale levensverwachting - Eerdere voorspellingen van maximum steeds verkeerd - Stijging max levensverwachting voorspelbaar: 1 jaar/4 jaar SCIENCE VOL 296 10 MAY 2002 Isala 9

Ontwikkelingen in de cardiologie Ziektebeeld Preventie Behandeling 1. Ischemische hartziekten ✔ ✔ 2. Ritmestoornissen ✔ ✔ 3. Kleppen ✔ ✔ 4. Hartfalen ✔ ✔ Isala 10

Ontwikkelingen in de cardiologie Ziektebeeld Preventie Behandeling 1. Ischemische hartziekten ✔ ✔ 2. Ritmestoornissen ✔ ✔ 3. Kleppen ✔ ✔ 4. Hartfalen ✔ ✔ Maar geldt dat ook voor ouderen???? Isala 11

Statins for Secondary Prevention in Elderly Patients Isala 12

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

Sprint Trial, intensive vs standard, 28% >75 N Engl J Med 2015;373:2103-6 Isala 14

Invasive treatment of MI (non-STEMI) Karen P. Alexander et al. Circulation. 2007;115:2549-2569 Isala 15

Treatment of STEMI in the elderly More benefit of primary PCI with increasing age J Am Coll Cardiol Intv 2010;3:324 – 31 Isala

Stroke prevention by warfarin Prevented strokes / 1000 / yr 10 12 6 >75 <75 SPAF II, Lancet 1994;343:687-691 Isala 17

We can induce regression of atherosclerosis Stable angina, before … and after 4 years medical treatment 2017:376;14 Isala 18

Sterfte aan hart- en vaatziekten neemt af (NL) STERFTE 1996 2015 2016 Mannen Kanker 21244 24692 25350 H&V 25208 18567 18148 Vrouwen Kanker 17027 21098 21626 H&V 26105 20812 20499 Isala 19

Effecten biventriculaire pacemaker Isala 20

Effects of hypertension treatment on dementia Isala

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 Isala 22

Verwachte ziektelast: 2012 Isala 23

Verwachte ziektelast: 2030 Isala 24

2. Limited public awareness - Almost never too late to change prognosis Knowing ≠ doing - Isala 25

Easy ways to shorten your life… Don’t check your blood pressure, cholesterol or glucose - - Continue smoking - Pack on the pounds - Avoid exercise - Make bad dietary choices Isala 26

3. Elderly less (well) treated: undertreatment 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. Isala

3. Elderly less (well) treated: overtreatment Hambling, et al, Diab Med 2017;23:1219-27 Isala

4. Less evidence based medicine in elderly Isala

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. Isala Neth J Med. 2015 Jun;73(5):211-8

5. Limited experience with Shared Decision Making Isala

Evidence for Shared Decision Making - 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 Isala 32

Why no Shared Decision Making? Isala 33

Why no Shared Decision Making? - No time - Performing procedures important - Guidelines based treatment important - Not trained to do it - Are we paid for that? Isala

Vanwege tijd niet benoemde uitdagingen 1. Polyfarmacie 2. Kennis over heterogeniteit 3. Samenwerking verschillende disciplines (!) 4. Meer onderzoek naar wat ouderen zelf willen Isala 35

Take home messages Hoge leeftijd vaker “normaal”, ook > 100 1. 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 ook ouderen prognose kunnen veranderen 7. Bewustwording over- en onderhandeling De “ evidence based medicine ” bij ouderen meer ontwikkelen 8. 9. Gezamenlijke besluitvorming (patiënt, familie, verschillende gezondheidswerkers) bevorderen Isala