Impacto de los síndromes geriátricos en el manejo y pronóstico del paciente anciano con enfermedad cardiovascular

Abstract

The progressive aging population and the high incidence of cardiovascular disease in the elderly make this issue a major public health problem. First, we analyzed the causes of conservative management in patients with severe aortic stenosis (AS), as well as clinical characteristics and prognosis of these patients according to the reason for conservative management. We included all patients with symptomatic severe AS conservatively managed from the Influencia del Diagnóstico de Estenosis Aórtica Severa (IDEAS) registry (n=292). The main reasons for conservative management were: group I (comorbidity) in 128 patients (43.8%); group II (dementia) in 18 (6.2%); group III (advanced age) in 34 (11.6%); group IV (rejection by the patient) in 62 (21.2%) and group V (other reasons) in 50 (17.1%). There was a greater comorbidity burden and a higher surgical risk in group I, as well as a higher rate of mortality at one year (42.2%), more commonly due to non cardiac causes. In contrast, patients from group III had fewer comorbidities and lower mortality (20.6%). Secondly, we analyzed the impact of comorbidity as measured by the Charlson Index (CI) on the management and prognosis of nonagenarian patients with AS (n=177) from the IDEAS and Pronóstico de la Estenosis Grave Aórtica Síntomática del Octogenario (PEGASO) registries. A total of 56 patients (31.6%) had a low degree of comorbidity (CI <3). A strong association was observed between the degree of comorbidity and mortality at one year (p <0.001). Most patients (150/177, 84.7%) were managed conservatively. Predictors of conservative management were hospital management without TAVI facilities (p <0.001); lower functional class (p = 0.012) and lower mean transaortic gradient (p = 0.048). Management was not different according to the degree of comorbidity. Finally, we analyzed the prevalence of interatrial block (IAB), its association with frailty and other geriatric syndromes and its association with the incidence of atrial fibrillation (AF) at one year in consecutive elderly patients with myocardial infarction. We included 254 patients. Among patients in sinus rhythm, 149 presented a normal interatrial conduction (67.7%), 37 partial IAB (16.8%) and 34 advanced IAB (15.5%). There was a significant linear association between the degree of IAB and the prevalence of hypertension, previous stroke and mitral regurgitation. A non-significant linear trend was observed between the prevalence of frailty and the degree of IAB, without association with the rest of geriatric syndromes. A non-significant trend towards a higher incidence of AF or mortality in patients with advanced BIA in sinus rhythm (hazard ratio 1.51, 95% confidence interval 0.85-2.70, p = 0.164). Conclusions: a) Patients with symptomatic severe AS managed conservatively are a heterogeneous group. The patients rejected because of advanced age had lower comobidity and surgical risk, as well as a better clinical outcomes. b) Nonagenarians with severe AS are managed conservatively in almost 85% of cases. Despite the strong association between the degree of comorbidity and prognosis, clinical management was not different according to the degree of comorbidity. c) About one third of elderly patients with myocardial infarction presented BIA on the ECG. The data support the hypothesis that BIA is a pre-AF state. A non-significant linear trend was observed between the prevalence of frailty and the degree of IAB. Advanced BIA was associated with a trend towards a higher incidence of AF or death at one year

Date of Award	12 Nov 2018
Original language	Spanish
Supervisor	Manuel Martínez-Sellés (Director) & Antonio Bayes Genis (Director)