QUELS CHOIX POUR LA PERSONNE AGÉE? LES TROUBLES DU RYTHME: MEDICAMENTS OU PACEMAKER? LESQUELS

Transcription

1 QUELS CHOIX POUR LA PERSONNE AGÉE? LES TROUBLES DU RYTHME: MEDICAMENTS OU PACEMAKER? LESQUELS Prof L DE ROY

2 LES TROUBLES DU RYTHME: MEDICAMENTS OU PACEMAKER? LESQUELS 1. Les antiarythmiques (AAD) 2. Les anticoagulants (OAC) 3. Les pacemakers (PM) 4. Les défibrillateurs (DAI/ICD) 5. La resynchronisation (CRT)

3 Les Arythmies auriculaires

4 AF Prevalence Increases with Age Women Prevalence % Men < Age (years) Go AS. et al. JAMA 2001;285:

5 Guidelines ESC 2010 EHJ

6 Classification des principaux antiarythmiques: Vaughan-Williams Classe I A Disopyramide (Rythmodan ) Quinidine (Kinidine-Durettes ) Classe II β-bloquants Classe III Sotalol (Sotalex ) Amiodarone (Cordarone ) Procainamide (Pronestyl ) B Lidocaine (Xylocaïne ) Mexiletine (Mexitil ) C Propafenone (Rytmonorm ) Flecaïnide (Tambocor ) (Apocard R ) Cibenzoline (Cipralan ) Dronedarone (Multacq ) Classe IV Autres Verapamil (Isoptine ) Digitale(Lanoxin ) Diltiazem (Tildiem ) Adénosine (Adenocor ) (Striadyne )

7 Guidelines ESC 2010 EHJ

8 ANTIARYTHMIQUES et FONCTION RENALE

9 L isolation des veines pulmonaires

10 N= 103 / 2754 JCE 2012

11 LES ANTICOAGULANTS Guidelines for the management of AF EHJ 2010

12 LES ANTICOAGULANTS Guidelines for the management of AF EHJ 2010

13 Coumariniques vs Aspirine dans la FA de la personne âgée > 75 ans n: 973 BAFTA TRIAL Lancet 2007

14 Et le risque hémoragique? Guidelines for the management of AF EHJ 2010

15 Les Nouveaux Antithrombines: Dabigatran (Pradaxa) Anti Xa: Rivaroxaban (Xarelto) Apixaban (Eliquis) RE-LY Efficacité et risques hémorragiques identiques Pas de contrôles réguliers Courte durée d action et délai bref Prix?

16 DABIGATRAN

17 Les Bradycardies

18 LA DYSFONCTION SINUSALE Choix du Pacemaker : AAI? VVI? DDD?

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20 SINUS NODE DISEASE AAI DDD OR VVI CTOPP: n: 2568 mean age: 73 ± 10

21 SINUS NODE DISEASE AAIR OR DDDR DANPACE (2011): n: 1415 mean age: 73

22 LES BLOCS AURICULO-VENTRICULAIRES PACEMAKER CONFIGURATION: VVI or DDD?

23 LES BLOCS AURICULO-VENTRICULAIRES > 70y UKPACE NEJM 2005

24 N= y AM H J 2003

25 LES DÉFIBRILLATEURS ICD

26 ALL CAUSE MORTALITY N= 965 CIRC 2009

27 COÛT EFFICACITÉ Markov model Chan CIRC 2009

28 Evaluation éthique au cas par cas Consentement éclairé Problèmes de fin de vie L Basta AJGC 2006

29 Contre-indications..( )

30 LA RESYNCHRONISATION CRT

31 CARE-HF: Reductions in morbidity and mortality in elderly CRT patients CARE-HF sub-population of patients aged 70 years CRT reduced mortality and morbidity versus medical treatment alone (MT) in elderly patients CRT N=157 Control N=145 Hazard ratio (95% CI) P-value All cause mortality or unplanned CV hospitalization 43.3% 58.6% 0.67 ( ) All cause mortality 22.9% 39.3% 0.55 ( ) <0.001 All cause mortality or unplanned HF hospitalization 32.5% 54.5% 0.51 ( ) Mabo P et al. Circulation 2008;118:S949 (Abstract 8450). [CARE-HF, a Medtronic sponsored study]

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33 n = 15381

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36 Findings from IMPROVE HF: Underutilization of CRT in Elderly Underutilization of CRT is exaggerated in eligible elderly HF patients Patients Receiving Recommended HF Therapies by Age Tertiles at Baseline (All Patients) Patients (%) 84,6 89,9 80,3 85,9 81,4 73,1 39,7 42,9 33,6 ACEI/ARB Beta Blocker Yancy C et al. J Cardiac Fail 2007;13(suppl):S158. Abstract 290. CRT (CRTD/CRT-P) Age</=64 Age Age>76

37 CARE-HF: CRT improves QoL and cardiac function/status in the elderly CARE-HF sub-population of patients aged 70 years P=0.53 Presented at AHA Laviolle et al. Circulation 2008;118:S950b (Abstract 48540). 2. Leclercq C, et al. Circulation 2008;118:S619b (Abstract 826) Minnesota Living w/ HF P= Baseline P< Mo. LVEF 2 26% 26% Baseline 18 Mo. 18 Mo. LVESV (ml) 2 1 P= P< % 31% P= Baseline CRT On CRT Off P< Mo.

38 MIRACLE study program demonstrates CRT benefit in elderly patients MIRACLE + MIRACLE ICD P< patients: 368 < 65 years; years; 174 > 75 years No evidence of increased adverse event rates in most elderly group Age <65 3,0% 4,0% 0,8% Age ,6% Age >75 LVESV Change (ml) -0,4-0,5-0,8 P= ,4% Change in NYHA -0,8 P= ,2% Mean change at 6 months -0,5 Absolute LVEF Change -0,8 P<0.001 P=0.002 P=0.004 Age <65 Age Age > P< P= P<0.001 Age <65 Age Age >75 CRT On CRT Off Kron et al.j Interv Card Electrophysiol:2009 Jan 19. [Epub ahead of print Jan 19]

39 Do elderly patients benefit from CRT? Recent analyses of randomized controlled trials provide data on the efficacy and safety of CRT in the elderly Extended survival, improved quality of life, and improved cardiac function and status Guidelines are the same for elderly patients1 Life expectancy >1 year CRT-P may be considered to extend survival and improve quality of life in select elderly patients where defibrillation is not desired 1. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol, 2008; 51:

40 Number Needed to Treat To Save A Life NNTx years = 100 / (% Mortality in Control Group % Mortality in Treatment Group) Drugs 50 CRT ICD CRT 14 COMPANION (1Yr) 7,5 CRT CRT-D CARE-HF MUSTT (3Yr) (5Yr) MADIT MADIT II (2.4Yr) (3Yr) AVID SCD-HeFT COPER- SAVE NICUS (3Yr) Adapted from Auricchio A, Abraham W. Circulation 2004; 109; (4Yr) CIBIS II MERIT HF CAP- Amiodorone HOPE RICORN (0.8Yr) (3.5Yr) (1Yr) (1Yr) (1.5Yr) (2Yr) (4 Yr)

41 COMPANION: CRT-D and CRT-P Incremental Cost-Effectiveness Ratios 2-year analysis of COMPANION study CRT-P ICER = $19,600 per Quality-Adjusted Life-Year (QALY) CRT-D ICER = $43,000 per QALY Incremental Cost-Effectiveness Ratios of CRT-P/CRT-D ($/QALY) $ $ Benchmark $50,000/QALY $ Essentially getting two therapies for one price Well below generally accepted benchmarks for therapeutic interventions of $50,000 $100,000 per QALY $ $ $0 CRT-P Feldman AM, et al. J Am Coll Cardiol 2005; 46: [COMPANION sponsored by Guidant] CRT-D

42 Incremental Cost Per QALY Gained Effect of Starting Age and Device Longevity on Cost per QALY Base case 80,000 7 Years 70,000 5 Years 60,000 50,000 40,000 8 Years 30,000 20,000 10, Age at Starting Treatment CRT+MT vs MT CRT+ICD+MT vs CRT + MT CRT+ICD+MT vs MT

43 Conclusions Long-term treatment with CRT-P appears highly costeffective compared to medical therapy for any starting age The cost effectiveness of CRT-ICD compared to CRT-P is conditional on patient life expectancy and device longevity Where device longevity is adequate, and patient life expectancy with CRT-P is sufficient, CRT-ICD may also be considered cost-effective

44 75 Y Ermis C Europace 2007

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52 INSUFFISANCE CARDIAQUE

53 AF

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55 Results: Baseline Practice Characteristics By Age Tertiles ( 64y, 65-76y, >76y) Younger patients more likely to attend multispecialty, hospitalbased, and transplant-affiliated outpatient clinics (P<.001 all comparisons). Younger patients also more likely to receive care from outpatient practices with a dedicated heart failure clinic, and with electrophysiologists on staff (P<.001 all comparisons). By Sex Women were more likely than men (14.1% vs. 12.7%; P=.025) to attend a transplant-affiliated outpatient clinic. More women than men received care at practices with a device clinic (82.8% vs. 80.4%; P<.001) Yancy CW, et al. Am Heart J 2009;157:754-62

56 Baseline Patient Characteristics by Age Tertile 64 y n=5, y n=5,176 >76 y n=4,791 P Male 73% 73% 67% <.001 Ischemic etiology 53% 71% 73% <.001 Atrial fibrillation history 20% 32% 41% <.001 Diabetes 35% 38% 29% <.001 Hypertension history 58% 64% 64% <.001 Prior MI 34% 43% 42% <.001 CABG 22% 37% 35% <.001 LVEF, median, % <.001 SBP, median, mm Hg <.001 BUN, median, mg/dl <.001 Creatinine, median, mg/dl <.001 BNP, median, pg/ml <.001 QRS duration, median, ms <.001 Characteristic Yancy CW, et al. Am Heart J 2009;157:754-62

57 Results: Older Patients Less Likely to Receive Guideline-Indicated HF Therapies Eligible patients with treatment (%) 100% P< % 80% 75% P< % 86% 81% < 65y P= %71% 68% 73% P< % 50% 34% 65-76y P<.001 P= % 39% 34% 57% 52% >76y P< % 61% 57% 43% 27% 25% 0% ACEI/ARB Beta-blocker Aldosterone Anticoag. Antagonist for Atrial Fib. Yancy CW, et al. Am Heart J 2009;157: Cardiac Resynch. ICD HF Education

58 Results: Significant Differences when Stratified by Age and Sex When stratified by age and sex, differences in delivery of guidelineindicated care most striking for: Aldosterone antagonist; Cardiac resynchronization (CRT or CRT-D) ICD (ICD or CRT-D) Aldosterone Antagonist 100% 50% 0% < 65y 34% 100% 50% 0% < 65y P= % 43% 37% Males 65-76y >76y P= % 42% Males Yancy CW, et al. Am Heart J 2009;157: % 27% Females ICD or CRT-D 100% < 65y P< % 53% 59% 48% 0% 65-76y >76y P< % 50% 32% 30% Females 50% 26% Cardiac Resynchronization >76y P<.001 P< % 65-76y Males Females

59 Older and Female Patients Less Likely to Receive Some Care Measures By Sex Conformity to Care Measures Adjusted odds ratio with 95% CI displayed 1,14 By Increasing Age (per 10 years) Care Measure ACEI/ARB 0,87 P< ,85 P<.0001 P< ,93 P= ,79 Cardiac Resynchronization* 0,88 P=.0233 ICD/CRT-D* 0,94 P=.0023 P= ,44 P= ,04 P= ,42 P= ,16 P<.0001 HF Education 0,93 P<.0001 P=.0010 ß-Blocker 0,81 Aldosterone Antagonist * Significant age and sex interaction P= ,99 Anticoagulation for AF* 0,1 Younger More Likely Yancy CW, et al. Am Heart J 2009;157: Older More Likely 0,1 10 Females More Likely 1 Males More Likely 10

60 Conclusions Females and the more elderly are less likely to receive certain guideline-recommended evidence-based heart failure treatments in the outpatient setting Older patients received less pharmacologic therapy, less device therapy, and less heart failure education. Women received less heart failure education and less device therapy. Yancy CW, et al. Am Heart J 2009;157:754-62

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62 Aspirine: less effect after 75 y

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67 CTOPP SSS AVB n= 2568 NEJM 2008

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71 JICE 2011 Age moyen: 86.2 ans n: 149 Comparable to data from younger but higher 30 d all cause mortality

72 DEATH n = 1415 AF DANPACE 2011

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74 MOST Total Mortality or Stroke 0.50 Event Rate 0.40 Ventricular pacing P = 0.48 Adjusted P = Dual-chamber pacing No. at risk: Ventricular pacing Dual-chamber pacing Months Lamas G, et al. N Engl J Med 2002; 346:

75 MOST Conclusions In patients with SND, dual-chamber pacing (versus single-chamber ventricular pacing) REDUCES newly diagnosed and chronic atrial fibrillation, reduces the signs and symptoms of heart failure, and slightly improves quality of life. Dual-chamber pacing did NOT improve the rate of the primary endpoint of mortality or freedom from stroke.

76 SINUS NODE DISEASE DDD OR VVI MOST: n: 2010 mean age: 74 (67-80) NS

77 Pacemaker Configurations VVI Indications The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation).

78 Pacemaker Configurations DDD

79 C. 70 y: recurrent syncope I avr V1 V4 II avr V2 V5 avf V3 V6 III I V AAI pacing 70/min CAVB: 12 s asystole Suspected level of block: nodal H. 71 y: syncope ECG: Normal (PR 158 ms, QRS 88ms) CAVB :11 s asystole Supposed level of block: nodal

80 Les stimulateurs cardiaques

81 Anatomy of a Pacemaker Resistors Atrial connector Connector Ventricular connector Defibrillation protection Output capacitors Hybrid Clock Reed (Magnet) switch Battery Telemetry antenna

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83 Kaszala K, Ellenbogen K AJGC 2006

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85 ICD AND AGE CIRC 2009

86 N= 965 CIRC 2009

87 PENGO THROMBOSIS AND HEMOSTASISI 2011

88 PENGO THROMBOSIS AND HEMOSTASISI 2011

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