Statins for Secondary Prevention in Elderly Patients
A Hierarchical Bayesian Meta-Analysis
Jonathan Afilalo, Gustavo Duque, Russell Steele, J. Wouter Jukema, Anton J.M. de Craen, and Mark J.
J Am Coll Cardiol Volume 51, Issue 1, January 1/8, 2008
Objectives: This study was designed to determine whether statins reduce all-cause mortality in elderly patients with coronary heart disease.
Background: Statins continue to be underutilized in elderly patients because evidence has not consistently shown that they reduce mortality.
Methods: We searched 5 electronic databases, the Internet, and conference proceedings to identify relevant trials. In addition, we obtained unpublished data for the elderly patient subgroups from 4 trials and for the secondary prevention subgroup from the PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) trial. Inclusion criteria were randomized allocation to statin or placebo, documented coronary heart disease, 50 elderly patients (defined as age 65 years), and 6 months of follow-up. Data were analyzed with hierarchical Bayesian modeling.
Results: We included 9 trials encompassing 19,569 patients with an age range of 65 to 82 years. Pooled rates of all-cause mortality were 15.6% with statins and 18.7% with placebo. We estimated a relative risk reduction of 22% over 5 years (relative risk [RR] 0.78; 95% credible interval [CI] 0.65 to 0.89). Furthermore, statins reduced coronary heart disease mortality by 30% (RR 0.70; 95% CI 0.53 to 0.83), nonfatal myocardial infarction by 26% (RR 0.74; 95% CI 0.60 to 0.89), need for revascularization by 30% (RR 0.70; 95% CI 0.53 to 0.83), and stroke by 25% (RR 0.75; 95% CI 0.56 to 0.94). The posterior median estimate of the number needed to treat to save 1 life was 28 (95% CI 15 to 56).
Conclusions: Statins reduce all-cause mortality in elderly patients and the magnitude of this effect is substantially larger than had been previously estimated.
Showing posts with label Elderly. Show all posts
Showing posts with label Elderly. Show all posts
Friday, January 4, 2008
Thursday, August 30, 2007
Warfarin Versus Aspirin for Stroke Prevention in an Elderly Community Population With Atrial Fibrillation
Title: Warfarin Versus Aspirin for Stroke Prevention in an Elderly Community Population With Atrial Fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): A Randomised Controlled Trial
Topic: Arrhythmias
Date Posted: 8/28/2007
Author(s): Mant J, Hobbs FD, Fletcher K, et al.
Citation: Lancet. 2007;370:493-503.
Clinical Trial: Yes
Study Question: Does warfarin reduce the risk of major stroke, arterial embolism, or other intracranial hemorrhage, compared with aspirin in elderly patients with atrial fibrillation?
Methods: The authors report the results of the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study, a randomized, open-label trial of aspirin versus warfarin in subjects over age 75 with atrial fibrillation. Patients were excluded if they had increased risk for gastrointestinal bleeding, rheumatic heart disease, intracranial hemorrhage, blood pressure >180/110 mm Hg, or at prohibitive risk for bleeding with warfarin, in their physician’s judgment. Subjects were randomized to warfarin (target INR 2-3), or aspirin 75 mg daily, for a mean of 2.7 years’ follow-up. The primary outcome was fatal or nonfatal stroke, intracranial hemorrhage, or clinically significant arterial embolism. Secondary outcomes were major hemorrhage, other vascular events, and all-cause mortality.
Results: The authors report 973 subjects were randomized from April 2001 to November 2004, among whom there were 24 primary events in the warfarin group (21 strokes, two other intracranial hemorrhages, and one systemic embolus), and 48 events in the aspirin group (44 strokes, one other intracranial hemorrhage, and three systemic emboli), (relative risk, 0.48; 95% confidence interval, 0.28-0.80; p = 0.003). This resulted in a yearly risk for primary event of 1.8% and 3.8% in the two groups, respectively. The yearly risk of extracranial hemorrhage was 1.4% (warfarin) versus 1.6% (aspirin) (relative risk, 0.87; 0.43-1.73).
Conclusions: The authors concluded that the data support the use of warfarin in patients with atrial fibrillation over age 75, unless there are contraindications, or the patient refuses warfarin therapy.
Perspective: There is a common misconception that benefits of medical therapy are fixed, while risks associated with medical therapy vary. This fallacy has led to the belief that greater risk of bleeding with advancing age makes warfarin therapy in the elderly more risky. Forgotten is the fact that risk of thromboembolic stroke from atrial fibrillation also increases with age. This same phenomenon is seen in a number of other medical conditions. Our training to compare ‘risk versus benefits’ leads, I believe, to this error in thinking. Benefits are reported and thought of as fixed (e.g., ‘warfarin lowers risk of stroke in atrial fibrillation x%’), whereas risks of therapy are seen as relative to the patient’s condition, age, and other risk factors. This error of medical decision making is compounded by the exclusion of the elderly from clinical trials—leaving us without adequate data. Ideally, we should assess both the risk of therapy, as well as the risk of not taking therapy, on an individual basis for each patient, based on available data (a ‘risk vs. risk’ comparison, rather than ‘risk vs. benefit’). Clearly, more clinical trial data that include the elderly are crucial. And we should remember that if a treatment is effective, it is logically more effective in groups at higher risk from complications of disease, and that usually means the elderly
Topic: Arrhythmias
Date Posted: 8/28/2007
Author(s): Mant J, Hobbs FD, Fletcher K, et al.
Citation: Lancet. 2007;370:493-503.
Clinical Trial: Yes
Study Question: Does warfarin reduce the risk of major stroke, arterial embolism, or other intracranial hemorrhage, compared with aspirin in elderly patients with atrial fibrillation?
Methods: The authors report the results of the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study, a randomized, open-label trial of aspirin versus warfarin in subjects over age 75 with atrial fibrillation. Patients were excluded if they had increased risk for gastrointestinal bleeding, rheumatic heart disease, intracranial hemorrhage, blood pressure >180/110 mm Hg, or at prohibitive risk for bleeding with warfarin, in their physician’s judgment. Subjects were randomized to warfarin (target INR 2-3), or aspirin 75 mg daily, for a mean of 2.7 years’ follow-up. The primary outcome was fatal or nonfatal stroke, intracranial hemorrhage, or clinically significant arterial embolism. Secondary outcomes were major hemorrhage, other vascular events, and all-cause mortality.
Results: The authors report 973 subjects were randomized from April 2001 to November 2004, among whom there were 24 primary events in the warfarin group (21 strokes, two other intracranial hemorrhages, and one systemic embolus), and 48 events in the aspirin group (44 strokes, one other intracranial hemorrhage, and three systemic emboli), (relative risk, 0.48; 95% confidence interval, 0.28-0.80; p = 0.003). This resulted in a yearly risk for primary event of 1.8% and 3.8% in the two groups, respectively. The yearly risk of extracranial hemorrhage was 1.4% (warfarin) versus 1.6% (aspirin) (relative risk, 0.87; 0.43-1.73).
Conclusions: The authors concluded that the data support the use of warfarin in patients with atrial fibrillation over age 75, unless there are contraindications, or the patient refuses warfarin therapy.
Perspective: There is a common misconception that benefits of medical therapy are fixed, while risks associated with medical therapy vary. This fallacy has led to the belief that greater risk of bleeding with advancing age makes warfarin therapy in the elderly more risky. Forgotten is the fact that risk of thromboembolic stroke from atrial fibrillation also increases with age. This same phenomenon is seen in a number of other medical conditions. Our training to compare ‘risk versus benefits’ leads, I believe, to this error in thinking. Benefits are reported and thought of as fixed (e.g., ‘warfarin lowers risk of stroke in atrial fibrillation x%’), whereas risks of therapy are seen as relative to the patient’s condition, age, and other risk factors. This error of medical decision making is compounded by the exclusion of the elderly from clinical trials—leaving us without adequate data. Ideally, we should assess both the risk of therapy, as well as the risk of not taking therapy, on an individual basis for each patient, based on available data (a ‘risk vs. risk’ comparison, rather than ‘risk vs. benefit’). Clearly, more clinical trial data that include the elderly are crucial. And we should remember that if a treatment is effective, it is logically more effective in groups at higher risk from complications of disease, and that usually means the elderly
Wednesday, August 22, 2007
Valvular Aortic Stenosis in the Elderly.[Review]
Author
Aronow, Wilbert S. MD, FACC, FAHAInstitution
From the Cardiology Division, Department of Medicine, New York Medical College, Valhalla, New York.
Title
Valvular Aortic Stenosis in the Elderly.[Review]
Source
Cardiology in Review. 15(5):217-225, September/October 2007.
Abstract
Elderly patients with valvular aortic stenosis have an increased prevalence of coronary risk factors, of coronary artery disease, and evidence of other atherosclerotic vascular diseases.
Statins may reduce the progression of aortic stenosis (AS).
Angina pectoris, syncope or near syncope, and congestive heart failure are the 3 classic manifestations of severe AS.
Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination.
Doppler echocardiography is used to diagnose the prevalence and severity of AS.
The indications for cardiac catheterization and the medical management of AS are discussed.
Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS.
Other indications for AVR are discussed.
Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition.
Patients with a bioprosthetic aortic valve without any of these 4 risk factors should be treated with aspirin 75-100 mg daily.
Aronow, Wilbert S. MD, FACC, FAHAInstitution
From the Cardiology Division, Department of Medicine, New York Medical College, Valhalla, New York.
Title
Valvular Aortic Stenosis in the Elderly.[Review]
Source
Cardiology in Review. 15(5):217-225, September/October 2007.
Abstract
Elderly patients with valvular aortic stenosis have an increased prevalence of coronary risk factors, of coronary artery disease, and evidence of other atherosclerotic vascular diseases.
Statins may reduce the progression of aortic stenosis (AS).
Angina pectoris, syncope or near syncope, and congestive heart failure are the 3 classic manifestations of severe AS.
Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination.
Doppler echocardiography is used to diagnose the prevalence and severity of AS.
The indications for cardiac catheterization and the medical management of AS are discussed.
Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS.
Other indications for AVR are discussed.
Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition.
Patients with a bioprosthetic aortic valve without any of these 4 risk factors should be treated with aspirin 75-100 mg daily.
Saturday, August 11, 2007
Refusal Of Medical And Surgical Interventions Common Among Chronically Ill Elderly
Refusal Of Medical And Surgical Interventions Common Among Chronically Ill Elderly
11 Aug 2007
Chronically ill older persons frequently refuse medical and surgical interventions recommended by their physicians, according to a recent study by Yale School of Medicine researchers.
11 Aug 2007
Chronically ill older persons frequently refuse medical and surgical interventions recommended by their physicians, according to a recent study by Yale School of Medicine researchers.
The study suggests that physicians continue to recommend invasive or risky interventions for people with advanced illness despite the patient's view that these treatments may be too burdensome, or that the treatment doesn't fit with their goals of care.
"Physicians need to offer treatment alternatives that better fit their patients' goals and preferences," said first author Marc Rothman, M.D., postdoctoral fellow in geriatrics in the Department of Internal Medicine at Yale.
Published in the Journal of General Internal Medicine, the study explored the treatment preferences of 226 persons age 60 and older with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease. Trained research assistants conducted in-home interviews with participants at least every four months for up to two years, but more frequently if the patient's health status changed (i.e., hospitalizations or initiation of hospice services).
Patients were asked whether they had refused or undergone any treatments recommended by their physicians, and why. They were asked to estimate their own longevity, about their desire for prognostic information from physicians, and about their prior experiences with medical decision-making.
Researchers found that 16 percent of these patients reported refusing one or more medical or surgical interventions recommended by their physician. The most frequently refused interventions were cardiac catheterization and surgery, with refusal rates of over 10 percent. Other interventions refused included chemotherapy, radiation, intubation, dialysis, and transplantation. Hospitalization was rarely refused.
The most common reasons given for treatment refusals were fear of side effects. Patients who refused treatments were more likely to have congestive heart failure, to rate their own longevity at less than two years, and to want their physicians to discuss their prognosis with them. The mortality rate among those who had refused treatments was higher than those who had not.
"Our study highlights the frequency with which older persons with advanced illness refuse treatments recommended by their physicians," said Rothman. "This frequency of refusal suggests that physicians may be recommending treatments for these patients that pose unacceptable burdens or that fail to meet patients' goals. Patients with advanced illness may require a broader range of treatment alternatives, so that they can select the option that best meets their goals of care."
Tuesday, August 7, 2007
Reduced mortality in treatment group halts BP trial in elderly
Reduced mortality in treatment group halts BP trial in elderly
August 7, 2007
London, UK - The largest ever study to look at the effects of lowering BP in those aged 80 and over—the Hypertension in the Very Elderly Trial (HYVET)—has been halted prematurely due to significant reductions in both stroke and overall mortality in the treatment arm [1].
One of the investigators, Dr Ruth Peters (Imperial College, London), told heartwire that the reductions in stroke and mortality observed "were statistically significant and not trivial." She declined, however, to give specific figures. "We are being really cautious about this." She said the plan is to simultaneously publish the results in a peer-reviewed journal and present them at a major medical meeting, "probably sometime next spring."
The decision to halt the study was taken by the steering committee following a recommendation to that effect from the data safety monitoring board last month. All patients in the study are being brought back to have their treatment reviewed and will have the option of switching to the active-therapy arm. The trial had been slated to end in 2009.
Great news for the over-80s
HYVET was being conducted in a number of countries in Eastern and Western Europe as well as in Tunisia and China and included 3845 patients aged 80 or older. HYVET was undertaken because previous smaller studies had produced inconclusive results with regard to whether blood-pressure lowering was beneficial or not in the very elderly. In some studies, although antihypertensive therapy reduced the risk of stroke, it did not reduce—and in some cases increased—mortality.
The entry criteria for HYVET were a sitting systolic blood pressure of 160 to 199 mm Hg and a diastolic BP of 90 to 109 mm Hg. Peters said that later on in the trial, patients with isolated systolic hypertension were also allowed to participate. Patients were randomized to either placebo or a low-dose diuretic (indapamide 1.5 mg sustained release) and an additional ACE inhibitor (perindopril 2 mg or 4 mg a day) if required.
The primary end point is stroke events (fatal and nonfatal), and secondary outcome measures include total mortality, cardiovascular mortality, cardiac mortality, stroke mortality, and skeletal fracture.
"It was not clear prior to our study whether the over-80s would benefit from blood-pressure-lowering medication in the same way as younger people," says lead investigator Dr Chris Bulpitt (Imperial College, London) in a press release.
"Our results are great news for people in this age group because they suggest that where they have high blood pressure, such treatment can cut their chances of dying as well as [suffering a] stroke," he added.
Source
Imperial College, London. Trial stops after stroke and mortality significantly reduced by blood-pressure-lowering treatment for those aged 80 and over [press release]. August 7, 2007. Available here.
August 7, 2007
London, UK - The largest ever study to look at the effects of lowering BP in those aged 80 and over—the Hypertension in the Very Elderly Trial (HYVET)—has been halted prematurely due to significant reductions in both stroke and overall mortality in the treatment arm [1].
One of the investigators, Dr Ruth Peters (Imperial College, London), told heartwire that the reductions in stroke and mortality observed "were statistically significant and not trivial." She declined, however, to give specific figures. "We are being really cautious about this." She said the plan is to simultaneously publish the results in a peer-reviewed journal and present them at a major medical meeting, "probably sometime next spring."
The decision to halt the study was taken by the steering committee following a recommendation to that effect from the data safety monitoring board last month. All patients in the study are being brought back to have their treatment reviewed and will have the option of switching to the active-therapy arm. The trial had been slated to end in 2009.
Great news for the over-80s
HYVET was being conducted in a number of countries in Eastern and Western Europe as well as in Tunisia and China and included 3845 patients aged 80 or older. HYVET was undertaken because previous smaller studies had produced inconclusive results with regard to whether blood-pressure lowering was beneficial or not in the very elderly. In some studies, although antihypertensive therapy reduced the risk of stroke, it did not reduce—and in some cases increased—mortality.
The entry criteria for HYVET were a sitting systolic blood pressure of 160 to 199 mm Hg and a diastolic BP of 90 to 109 mm Hg. Peters said that later on in the trial, patients with isolated systolic hypertension were also allowed to participate. Patients were randomized to either placebo or a low-dose diuretic (indapamide 1.5 mg sustained release) and an additional ACE inhibitor (perindopril 2 mg or 4 mg a day) if required.
The primary end point is stroke events (fatal and nonfatal), and secondary outcome measures include total mortality, cardiovascular mortality, cardiac mortality, stroke mortality, and skeletal fracture.
"It was not clear prior to our study whether the over-80s would benefit from blood-pressure-lowering medication in the same way as younger people," says lead investigator Dr Chris Bulpitt (Imperial College, London) in a press release.
"Our results are great news for people in this age group because they suggest that where they have high blood pressure, such treatment can cut their chances of dying as well as [suffering a] stroke," he added.
Source
Imperial College, London. Trial stops after stroke and mortality significantly reduced by blood-pressure-lowering treatment for those aged 80 and over [press release]. August 7, 2007. Available here.
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