ATLANTA, Nov 08 (Reuters Health) -- Among patients with coronary heart disease (CHD), those over age 75 are five times less likely than younger patients to receive intensive treatment -- but aggressive treatment can benefit older patients, researchers reported here at an American Heart Association meeting. A panel discussion on medical ethics of caring for the elderly took place on Sunday, the meeting's opening day.
Patients with the greatest risk of dying from heart disease should receive the most aggressive treatment, regardless of age, Dr. Eric D. Peterson said as he presented findings of a study of 2,613 patients aged 75 or older who underwent cardiac catheterization at Duke University in Durham, North Carolina. Peterson compared survival in this group with that of younger patients after treatments including procedures such as bypass surgery or balloon angioplasty, or non-invasive, medical management alone.
Overall, 26% of the elderly group underwent bypass surgery, 30% had angioplasty, and 44% were managed conservatively. Five-year survival in very elderly patients with disease in more than one coronary artery was 69% after angioplasty, where a tiny balloon is used to clear blockages in the artery, and 65% after bypass surgery -- not a very significant difference, Peterson said. But 5-year survival was only 43% with medical management in high-risk patients.
"The magnitude of benefit (of aggressive management of CHD) is actually greater in older patients.... (Physicians) have tended to use aggressive treatment less because the risks were too high," Peterson told Reuters Health. He noted that informed consent for revascularization procedures has been difficult because most large studies of the procedures either have very small numbers of elderly patients or outright exclude them. The Duke study results could help elderly patients weigh the risks and benefits of aggressive treatment, he suggests.
Meanwhile, Dr. Jennifer A. Mattera of Yale University in New Haven, Connecticut, reviewed the care of 1,604 Medicare patients hospitalized with unstable angina, and found that 43% of those at high risk did not receive cardiac catheterization or stress testing, steps recommended by official guidelines.
Primary reasons for nonadherence to the guidelines were type of hospital and age of the patient. The older the patient, especially those over 85, the less likely the guidelines were to be implemented.
Co-panelist Dr. William Hazzard of the University of Washington, Seattle, also noted that treatment of heart disease in elderly patients often must rely in the results of studies that excluded them. "There has been exponential growth in cardiovascular disease in those over 75 in this country," Hazzard asserted. "We have neglected this change in the population." He added that "most of the attention on care of the elderly has focused on spending" rather than on healthcare delivery.
