B P10 C90 Cardiovascular Disease In Older Adults

Question 1

Identify the trial

10,003 symptomatic patients with intermediate pretest likelihood of CHD were randomized to anatomical testing with coronary computed tomographic angiography (CCTA) or to functional testing (i.e., a stress test).

Over a median follow-up of 25 months, the primary outcome of death, MI, hospitalization for unstable angina, or major procedural complication occurred in 3.3% of the CCTA group and 3.0% of the stress test group, with no difference between groups and similar findings in patients younger or older than age 65.

Answer 1

PROMISE trial

These findings indicate that the risk of a major adverse cardiac event during a 2-year follow-up period is quite low, and suggest that a conservative strategy, without testing, is reasonable for patients who prefer to avoid testing.

Question 2

Identify the trial

Randomized 5179 patients with moderate to severe ischemia on stress testing to an initial invasive strategy with coronary angiography and revascularization if indicated, or to an initial conservative strategy with intensive medical therapy.

Over a median follow-up of 3.2 years, there was no difference between groups in the primary outcome of CV death or MI, with similar findings across age groups.

Answer 2

ISCHEMIA trial

Patients randomized to the invasive strategy had better QOL, especially if they were more symptomatic at baseline. These results again provide rationale for conservative management, even in patients with moderate to severe symptoms, if the patient prefers to avoid testing and subsequent procedures.

Question 3

Identify the trial

Symptom relief and exercise capacity during 4-year follow-up were better with revascularization than with optimized medical therapy alone in older patients with CHD

Answer 3

TIME trial
Trial of Invasive versus Medical therapy in Elderly patients (TIME)

Invasive coronary angiography and revascularization are recommended for older adults with refractory symptoms, particularly those with significant ischemia on noninvasive diagnostic tests.

Question 4

Identify the trial

441 patients with ATTR cardiomyopathy (median age 75 years, 90% male, 81% white) tafamidis was associated with a 30% reduction in all-cause mortality, 32% reduction in CV-related hospitalizations, and better exercise tolerance and HF-related QOL over 30 months compared with placebo

Answer 4

ATTR-ACT trial

Question 5

Identify the trial

This assessed a more lenient rate control strategy. Therapy targeting heart rate <110 beats/min in older adults (Class IIb) without significant symptoms, CHD, or HF was comparable to strict rate control (<80 beats/min), 97 which may help to reduce need for cardiac pacing secondary to bradycardia.

Answer 5

RACE II trial

Rate Control Efficacy in Permanent Atrial Fibrillation (RACE) II trial

Question 6

Identify

The trial which showed rhythm control strategy was associated with increased mortality in older adults

Answer 6

AFFIRM trial

Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial

Since a rhythm control strategy does not obviate the need for anticoagulation, a rate control strategy is preferable in older adults.

Question 7

The trial that suggests the p tial of catheter ablation to improve QOL in older subgroups.

Answer 7

CABANA trial

Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation

Question 8

Trials that showed older patients derive similar mortality benefit in CRT implantation. In addition, CRT therapy improves gait speed, QOL, and frailty score in older HFrEF patients.

Answer 8

Cardiac Resynchronization-Heart Failure (CARE-HF)

Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION)

Question 9

Identify the trial

Patients with a LVEF ≤30% and prior MI, ICD therapy improved survival in those age >70 years of age by more than 30% compared with conventional therapy

Answer 9

Multicenter Automatic Defibrillator I tion Trial (MADIT) II

Question 10

Meta-analysis of these secondary prevention trials showed that patients ≥75 years old were more likely to die a nonarrhythmic death and there was no benefit from an ICD

Answer 10

CASH
AVID
CIDS

Question 11

Identify the trial

This demonstrated a 39% significant decrease in fatal stroke, 21% significant decrease in all-cause mortality, and 64% significant decrease in HF over 1.8 years mean follow-up in 3845 patients ≥80 years old with systolic BP ≥160 mm Hg treated with the thiazide-like diuretic indapamide to a target BP of 150/80 mm Hg versus placebo

Answer 11

HYVET
HYpertension in the Very Elderly Trial (HYVET)

Question 12

This showed a 34% reduction in CV events and 33% reduction in mortality in 2636 patients aged ≥75 years with SBP >130 mm Hg randomized to a target of 120 mm Hg versus 140 mm Hg.

Answer 12

SPRINT trial
Systolic Blood Pressure Intervention Trial (SPRINT)

Target BP ≤130 mm Hg for persons in this age group

Only two trials showed significant reductions in total mortality, several showed substantial reductions in stroke and HF

Question 13

Ezetimibe is generally well t erated in older adults, though it reduced CV events by a modest 6%

Answer 13

IMPROVE-IT
Improved Reduction of Outcomes: Vytorin Efficacy International Trial

Question 14

This trial showed the PCSK9 inhibitor alirocumab added to high-intensity or maximum-tolerated statin treatment, reduced the primary composite endpoint of death from CHD, nonfatal MI, ischemic stroke, or unstable angina requiring hospitalization compared with placebo in 18,924 patients with a recent ACS.

Answer 14

ODYSSEY OUTCOMES

Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment with Alirocumab

Question 15

Icosapentethyl lowered elevated triglyceride levels an average of 18% and reduced major CV events by 25%. However, the benefit was blunted in patients ≥65 years (HR = 0.87) compared with those <65 years (HR = 0.65)

Answer 15

REDUCE-IT trial