Differences in ventricular arrhythmias developed by ischemic and nonischemic heart failure patients

1
VI Simposio Internazionale "Heart Failure
Prevention and Management From Drugs to Devices"
Firenze, 28-29 aprile 2005 Centro Congressi
Convitto della Calza
Invecchiamento e trattamento dello scompenso
quali parametri debbono porre i limiti nelle
indicazioni interventistiche? Andrea Di
Lenarda (Trieste)
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• The care of elderly with HF is a typical example
  of our need to move from hi-tech to hi-touch
  medical and social strategy to provide the best
  intervention to prevent hospitalisation and
  improve quality of life

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Age USA 80.1 Can 79.7
Plt0.001
Ko et al. Arch Intern Med 2005 165 2486-2492
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Treatments in HF patients

• Medical treatment
• Angiotensin-receptor blockers
• Antiarrhythmics
• ACE inhibitors
• Beta-blockers
• Calcium channel blockers
• Digitalis
• Diuretics
• Nitrates plus arteriodilator

• NON Medical treatment
• CABG
• Vavular surgery
• Cardiomyoplastic
• CRT
• ICD
• VAD
• Heart transplant

Zipes DP. Circulation. 1998982334-2351. Pitt B.
N Engl J Med. 20033481309-1321.
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Treatments in HF patients

• Medical treatment
• Angiotensin-receptor blockers
• Antiarrhythmics
• ACE inhibitors
• Beta-blockers
• Calcium channel blockers
• Digitalis
• Diuretics
• Nitrates plus arteriodilator

• NON Medical treatment
• CABG
• Valular surgery
• Cardiomyoplastic
• CRT
• ICD
• VAD
• Heart transplant

Zipes DP. Circulation. 1998982334-2351. Pitt B.
N Engl J Med. 20033481309-1321.
6

• Caratteristiche peculiari dellanziano con SC
• Scarsità di evidenze da trial clinici
• Scarsa aderenza agli interventi/LG
• Sopravvivenza e qualità della vita
• Aspettativa di vita e problematiche della fine
  della vita
• Eterogeneità biologica e clinica

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Prevalence of HF by Age and Gender

• United States NHANES III 1988-94

Percent Population
Ages
Source NHANES III (1988-94), CDC/NCHS, and the
American Heart Association
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Baseline Characteristics (1)
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Cardiac Resynchronization in elderly
InSync/InSync ICD Italian Registries

• Cardiac Resynchronization Therapy seems to
  provide beneficial effects in terms of
• clinical status
• functional status
• echo parameters
• regardless of the age.

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Cardiac Resynchronization in elderly
InSync/InSync ICD Italian Registries lt80 yo
(n1096) vs 80 yo (n85)

• There were no difference between the two groups
  in the of Responders
• improved NYHA Class
• no occurrence of hospitalization due to
  worsening HF

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Cardiac Resynchronization in elderly
InSync/InSync ICD Italian Registries
Improvement of NYHA Class Baseline vs Follow-up
in both groups Plt0.05
3.1?0.6
3.0?0.6
2.3?0.7
2.2?0.7
BaseLine
Follow-Up
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Cardiac Resynchronization in elderly
InSync/InSync ICD Italian Registries
Improvement of Ejection Fraction Baseline vs
Follow-up in both groups Plt0.05
35?11
37?12
28?10
27?10
Follow-Up
BaseLine
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Heart Failure in elderly

• Diastolic vs systolic HF
• Atrial fibrillation
• Polypharmacy and drug interactions
• Poor Compliance
• Evaluation of symptoms and quality of life
  (influenced by frailty and comorbidities)
• Social and economic issues

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Symptomatic CHF and ICD
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Clinical case L.A. 70 yo

• Dilated cardiomyopathy (diagnosis 1995)
• Optimal medical treatment
• 1/2005 NYHA IV, LVEF 25
• Home care continuous dobutamine Rx
  (port-a-cath)
• QRS 120 msec, no dissynchrony
• Prognostic evaluation terminally ill patient,
  very short life expectancy (weeks to month (s))
• Serial hospitalisations for refractory HF
• Death for refractory HF after 14 months (3/2006)

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Comorbidities in Medicare CHF patients
(n122,630 65 years)
Hypertension 55 Diabetes 31 COPD
26 Ocular disorders 24 Hypercholesterolemia
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Braunstein JB et al, JACC 2003 42 1226-33
Depression 11-56
Turvey CL et al, JAGS 2002 50 2003-8 De Geest S
et al, Eur J HF 2003 5 57-67
Mental impairment Musculoskeletal
problems Incontinence Renal failure CVA Anemia
Braunstein JB, JACC 2003 42 1226-33
Lien CT et al, Eur J HF 2002 4 91-8 Krum H
Gilbert RE, Lancet 2003 362 147-58
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anziano fragile

• soggetti di età avanzata, cronicamente affetti da
  patologie multiple, con stato di salute
  instabile, frequentemente disabili, in cui gli
  effetti dellinvecchiamento e delle malattie sono
  spesso complicati da problematiche di tipo
  socio-economico.
• rischio elevato di rapido deterioramento della
  salute e dello stato funzionale ed elevato
  consumo di risorse.
• nello SC la fragilità modula gli effetti della
  cardiopatia sulla prognosi

Linee Guida della Società Italiana di
Gerontologia e Geriatria sulla Valutazione
Multidimensionale nellanziano fragile
(www.sigg.it).
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Obiettivi del trattamento dello Scompenso
Cardiaco Cleland, Br Heart J 1994 72 (suppl)
73-79
età
comorbidità
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Device indications in elderly with HF

• Some old patients may benefit from BivPM (mainly
  objective QoL)
• The indication to ICD should be carefully
  evaluated with respect to SD vs non SD risk of
  dying and life expectancy (years)
• The impact of hi-tech medical strategy is
  progressively lower in elderly
• The expected increase of device indications in
  the future should take in deep consideration the
  impact for costs of health care

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Caratteristiche dellanziano con SC
Eterogeneità del quadro clinico
così?.
o così?!?
così?.
Comorbidità assenti Autonomia
conservata Cognitivo conservato Cond.sociale
buona Motivazione forte Target
sopravvivenza Cure aggressive Modello
successful aging
Comorbidità / - presenti Autonomia
limitata Cognitivo /-conservato Cond.sociale
/- buona Motivazione /- debole Target
sopravvivenza/QDV Cure moderatamente
aggressive Modello miglioramento funzionale e
outcome
Comorbidità multiple Autonomia
assente Cognitivo compromesso Cond.socialedefici
taria Motivazione assente Target QDV Cure
palliative Modello cure palliative
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