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Vol. 69. Issue 7.
Pages 710-711 (July 2016)
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Vol. 69. Issue 7.
Pages 710-711 (July 2016)
Letter to the Editor
DOI: 10.1016/j.rec.2016.02.024
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Chronic Ischemic Heart Disease in the Elderly. Consensus Document of the Spanish Societies of Cardiology, Internal Medicine, Primary Care, and Geriatrics
Cardiopatía isquémica crónica del anciano. Documento de consenso. Sociedades Españolas de Cardiología, Medicina Interna, Atención Primaria y Geriatría
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Manuel Martínez-Sellésa,
Corresponding author
mmselles@secardiologia.es

Corresponding author:
, Ricardo Gómez Huelgasb, Emad Abu-Assic, Alberto Calderónd, María Teresa Vidáne
a Sociedad Española de Cardiología (SEC), Sección de Cardiología Geriátrica, Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea y Universidad Complutense, Madrid, Spain
b Sociedad Española de Medicina Interna (SEMI), Departamento de Medicina Interna, Hospital Universitario Regional de Málaga, FIMABIS, Málaga, Spain
c Sociedad Española de Cardiología (SEC), Sección de Cardiopatía Isquémica y Cuidados Agudos Cardiovasculares, Servicio de Cardiología, Hospital Clínico Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
d Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Centro de Salud Rosa Luxemburgo, San Sebastián de los Reyes, Madrid, Spain
e Sociedad Española de Geriatría y Gerontología, Servicio de Geriatría, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
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Table. Geriatric Factors Evaluated
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To the Editor,

We would like to draw attention to the above document, which was recently published simultaneously in Medicina Clínica,1Revista Española de Geriatría y Gerontología,2and SEMERGEN-Medicina de familia.3 Chronic ischemic heart disease affects 5% to 7% of elderly patients, and the treatment approach requires a holistic assessment including comorbidities, frailty, functional status, polypharmacy, and drug interactions. These factors are so common and significant in making patient-centered decisions that some authors consider a subspecialty of geriatric cardiology warranted.4 Asymptomatic or atypical presentation is more common in individuals older than 75 years, and a high percentage of patients cannot exercise to a level sufficient to allow interpretation of stress testing. We advocate medical treatment in most patients. This should include lifestyle modifications. Drugs are often underused in elderly patients, compliance decreases with age,5 effectiveness is lower, adverse effects are more common, and there are more treatment interruptions. Statins are not indicated for patients older than 80 years with severe comorbidity or life expectancy < 3 years, moderate to severe dementia, or significant functional deterioration.6 With the exception of statins, the targets for low-density lipoprotein cholesterol levels and other factors (heart rate, blood pressure) are similar for elderly and general adult patients, although a target blood pressure of < 160 mmHg is sometimes acceptable. In elderly patients, the decision of whether or not to perform coronary revascularization should be made with caution, as interventional procedures and surgery carry a higher complications rate. Elderly patients with chronic ischemic heart disease frequently have comorbidities, frailty, or geriatric syndromes that limit the therapeutic possibilities and confer a worse prognosis. Most elderly patients demonstrate frailty criteria. Such criteria confer a 2-4 fold increase in mortality. Cognitive decline is also very common, which can make treatment adherence difficult. Likewise, depression, which confers a worse prognosis, and other comorbidities (diabetes mellitus, kidney disease) are frequently present. A holistic biopsychosocial assessment is essential, taking into account functional assessment, frailty, cognitive function, social situation, life expectancy, and the patient's wishes and directives (Table). Such an assessment is required to balance the risk-benefit ratio and be confident that in the prognostic prediction, the competing risk associated with these geriatric conditions is not higher than that associated with the coronary disease itself.

Table.

Geriatric Factors Evaluated

  Diagnosis  Prognosis/plan 
Comorbidity  DM, COPD, KD, bleeding risk, etc.
Geriatric syndromes (eg, falls, incontinence) 
Affect short-term and long-term outcomes
Higher risk in diagnostic and therapeutic procedures 
Frailty  Fried criteria
Clinical Frailty Scale
SPPB 
Risk of more severe coronary artery disease
Increased morbidity and mortality after intervention
Does not necessarily mean avoiding invasive investigations or treatments; does mean more personalized care 
Functional status  Katz index (basic ADLs)
Barthel index
Lawton index (instrumental ADLs) 
Increased risk of complications and death
If moderate-severe dependence, prioritize management to improve quality of life 
Mental state  MMSE
MoCA
miniCog
Depression test 
Independently associated with morbidity and mortality
Close follow-up, especially if depression is present 
Polypharmacy  ≥ 5 regular medications  Risk of interactions and nonadherence
Risk of side effects
Sometimes, drugs must be prioritized according to which are the most important to achieve the desired effect 

ADLs, activities of daily living; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; KD, kidney disease; miniCog, Mini-Cognitive Assessment Instrument, a simple test (2 questions and drawing a clock) for screening of cognitive decline; MMSE, Mini Mental Examination; MoCA, Montreal Cognitive Assessment; SPPB, Short Physical Performance Battery (assesses balance, walking speed, and ability to rise from sitting to standing).

Fried Criteria: assesses 5 criteria (involuntary weight loss, exhaustion, low physical activity, slow walking speed, and low muscle strength); 3 or more criteria indicate frailty. Clinical Frailty Scale: scale between 1 (very fit) and 9 (terminally ill); the assessment includes different deficits, illnesses, and disabilities.

Reproduced with permission from Martínez-Sellés et al.1

CONFLICTS OF INTEREST

E. Abu-Assi is Associate Editor of Revista Española de Cardiología.

References
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M. Martínez-Sellés, R. Gómez-Huelgas, E. Abu-Assi, A. Calderón, M.T. Vidán.
Cardiopatía isquémica crónica en el anciano.
Med Clin (Barc)., 146 (2016), pp. 372.e1-372.e10
[2]
M. Martínez-Sellés, R. Gómez-Huelgas, E. Abu-Assi, A. Calderón, M.T. Vidán.
Cardiopatía isquémica crónica en el anciano.
Rev Esp Geriatr Gerontol., 51 (2016), pp. 170-179
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M. Martínez-Sellés, R. Gómez-Huelgas, E. Abu-Assi, A. Calderón, M.T. Vidán.
Cardiopatía isquémica crónica en el anciano.
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S.P. Bell, N.M. Orr, J.A. Dodson, M.W. Rich, N.K. Wenger, K. Blum, et al.
What to expect from the evolving field of geriatric cardiology.
J Am Coll Cardiol., 66 (2015), pp. 1286-1299
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P. Garg, H.C. Wijeysundera, L. Yun, W.J. Cantor, D.T. Ko.
Practice patterns and trends in the use of medical therapy in patients undergoing percutaneous coronary intervention in Ontario.
J Am Heart Assoc., (2014), pp. 3
[Epub ahead of print]. pii: e000882. Available at: http://dx.doi.org/10.1161/JAHA.114.000882
[6]
R. Gómez-Huelgas, M. Martínez-Sellés, F. Formiga, J.J. Alemán Sánchez, M. Camafort, E. Galve, et al.
[Management of vascular risk factors in patients older than 80].
Med Clin (Barc), 143 (2014), pp. 134
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