"Use of invasive procedures drops with age, precipitously after age 75," says Dr. Karen Alexander, a professor of medicine at Duke University Medical Center who presented a report on the finding today at the annual scientific session of the American College of Cardiology in Atlanta. "It is important that health-service researchers look at whether this is appropriate, or whether some people who we do not treat could benefit from the procedures."
Her data comes from an analysis of two international trials designed to test the effectiveness of a new drug in patients with heart problems.Of the 15,000 patients in the trials, 11.3 percent were 75 or older. Only 52 percent of them had catheterization, compared to 63 percent of the younger patients, and 28 percent had angioplasties, compared to 37 percent of the younger group. While there was a slight increase in bypass surgeries -- 8 percent for those over 75 and 7 percent for the younger people -- analysis of their risk factors indicated that there should have been more surgery.
Unwillingness of older patients to have these procedures is only a small contributor to the decline, Alexander says. She found that out by questioning 678 patients, 40 percent of whom were 75 and older. All had been admitted to Duke University Hospital after experiencing chest pain.
"We asked whether they were willing to consider angioplasty or bypass surgery," Alexander says. "The willingness to decline increased with age, but the majority were still willing to have the procedures. Up to 70 percent said they would have angioplasty, and 50 percent said they would have bypass surgery. And only 30 percent of the patients said there is an age beyond which they would refuse bypass surgery."
It's possible cardiologists might be reluctant to prescribe the invasive treatments because they are uncertain of the risk-benefit relationship in older patients, Alexander says, adding that such information about benefits and risks comes from clinical trials, and only 2 percent of all trials enroll patients over 75.
She is now designing a study to determine which elderly patients have the most to gain from the procedures.
Age itself generally is not a barrier, says Dr. Marie-Florence Shadlen, professor of medicine in the University of Washington division of gerontology. "There is lots of research on the effect of age on outcome, and most of the research says that aging is not a contraindication to those interventions."
However, many older patients have illnesses other than their primary heart problems, Shadlen adds, and these "co-morbidities" complicate the picture.
For example, she says, people with diabetes tend to have problems with small blood vessels that will not be helped by angioplasty or bypass surgery.
Alexander says she factored co-morbidity into her analysis, and still concluded there was an age-related disparity in treatment.
What To Do
"The key is what happens when the patient and physician are discussing the patient's medical situation, and the available options for treating it," Alexander says. "We want to make sure that patients who could potentially benefit from these procedures are not being subtly or overtly dissuaded from having these procedures based solely on age."