quels choix pour la personne agÉe ? les troubles du …
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LES TROUBLES DU RYTHME:
MEDICAMENTS OU PACEMAKER?
LESQUELS
Prof L DE ROY
QUELS CHOIX POUR LA PERSONNE AGÉE ?
• 1. Les antiarythmiques (AAD)• 2. Les anticoagulants (OAC)• 3. Les pacemakers (PM)• 4. Les défibrillateurs (DAI/ICD)• 5. La resynchronisation (CRT)
LES TROUBLES DU RYTHME:
MEDICAMENTS OU PACEMAKER?
LESQUELS
Les Arythmies auriculairesLes Arythmies auriculaires
4Go AS. et al. JAMA 2001;285:2370-2375.
0.1 0.2 0.4 0.9 1.01.7 1.7
3.0 3.4
5.0 5.0
7.3 7.2
10.39.1
11.1
0
2
4
6
8
10
12
< 55 55-59 60-64 65-69 70-74 75-79 80-84 ≥ 85
Age (years)
Prev
alen
ce %
AF Prevalence Increases with Age
Men
Women
Guidelines ESC 2010 EHJ
Classification des principaux antiarythmiques: Vaughan-WilliamsClassification des principaux antiarythmiques: Vaughan-Williams
Classe I Classe II Classe III Classe IV Autres ADisopyramide (Rythmodan ) β-bloquants Sotalol (Sotalex) Verapamil (Isoptine) Digitale(Lanoxin)
Quinidine (Kinidine-Durettes) Amiodarone Diltiazem (Tildiem) Adénosine (Cordarone) (Adenocor)
(Striadyne )
Procainamide (Pronestyl)
B
Lidocaine (Xylocaïne )
Mexiletine (Mexitil )
CPropafenone (Rytmonorm )
Flecaïnide (Tambocor )
(Apocard R )
Cibenzoline (Cipralan )
Dronedarone (Multacq )
Guidelines ESC 2010 EHJ
ANTIARYTHMIQUES et FONCTION RENALE
L’isolation des veines pulmonaires
JCE 2012N= 103 / 2754
Guidelines for the management of AF EHJ 2010
LES ANTICOAGULANTS
Guidelines for the management of AF EHJ 2010
LES ANTICOAGULANTS
BAFTA TRIAL Lancet 2007
Coumariniques vs Aspirine dans la FA de la personne âgée > 75 ans
n: 973
Guidelines for the management of AF EHJ 2010
Et le risque hémoragique ?
RE-LY
Les Nouveaux
Antithrombines:
Dabigatran (Pradaxa)
Anti Xa:
Rivaroxaban (Xarelto) Apixaban (Eliquis)
• Efficacité et risques hémorragiques identiques• Pas de contrôles réguliers• Courte durée d’action et délai bref• Prix ?
DABIGATRAN
Les Bradycardies
LA DYSFONCTION SINUSALE
Choix du Pacemaker : AAI ?VVI ?DDD ?
SINUS NODE DISEASE
CTOPP: n: 2568 mean age: 73 ± 10
AAI
DDD
VVIOR
SINUS NODE DISEASE
DANPACE (2011): n: 1415
mean age: 73
AAIR
DDDR
OR
PACEMAKER CONFIGURATION: VVI or DDD?
LES BLOCS AURICULO-VENTRICULAIRES
LES BLOCS AURICULO-VENTRICULAIRES
UKPACE NEJM 2005> 70y
AM H J 2003N= 1588 ≥ 80 y
ICD
LES DÉFIBRILLATEURS
CIRC 2009
ALL CAUSE MORTALITY
N= 965
COÛT EFFICACITÉ
Chan CIRC 2009Markov model
L Basta AJGC 2006
• Evaluation éthique au cas par cas• Consentement éclairé• Problèmes de fin de vie
Contre-indications
…..(07-2011)
LA RESYNCHRONISATION CRT
54.5%
39.3%
58.6%
Control N=145
<0.0010.55 (0.36-0.84)22.9%All cause mortality
0.00010.51 (0.36-0.73)32.5%All cause mortality or un-planned HF hospitalization
0.0150.67 (0.48-0.92)43.3%All cause mortality or un-planned CV hospitalization
P-valueHazard ratio
(95% CI)CRT
N=157
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
Mabo P et al. Circulation 2008;118:S949 (Abstract 8450). [CARE-HF, a Medtronic sponsored study]
n = 15381
Yancy C et al. J Cardiac Fail 2007;13(suppl):S158. Abstract 290.
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)
89,9
39,7
80,385,9
42,9
73,181,4
33,6
84,6
ACEI/ARB BetaBlocker
CRT (CRT-D/CRT-P)
Pat
ient
s (%
)
Age</=64Age 65-76Age>76
CARE-HF: CRT improves QoL and cardiac function/status in the elderly
Minnesota Living w/ HF
4229 27
44 38 35
Baseline 3 Mo. 18 Mo.
• CARE-HF sub-population of patients aged ≥70 years
• Presented at AHA 2008
1. Laviolle et al. Circulation 2008;118:S950b (Abstract 48540). 2. Leclercq C, et al. Circulation 2008;118:S619b (Abstract 826)
P=0.50 P<0.001 P=0.001
■ CRT On ■ CRT Off
LVEF
26%37%
26% 31%
Baseline 18 Mo.
LVESV (mL)
217124
223 182
Baseline 18 Mo.
P<0.001P=0.53
P=0.40 P<0.001
1
2
2
MIRACLE study program demonstrates CRT benefit in elderly patients
5,2%
3,0%4,0%
1,4%0,6%0,8%
Age <65 Age 65-75 Age >75
• MIRACLE + MIRACLE ICD• Mean change at 6 months• 839 patients: 368 < 65 years; 297 65 – 75 years; 174 > 75 years• No evidence of increased adverse event rates in most elderly group
Change in NYHA
-0,8 -0,8 -0,8-0,5 -0,5 -0,4
Age <65 Age 65-75 Age >75
LVESV Change (mL)
-43 -23-8-18 -1
4
Age <65 Age 65-75 Age >75
Absolute LVEF Change
Kron et al.J Interv Card Electrophysiol:2009 Jan 19. [Epub ahead of print Jan 19]
■ CRT On ■ CRT Off
P<0.001 P=0.002 P=0.004
P=0.008P<0.001
P=0.002
P<0.001P<0.001
P=0.06
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; 51:2085-2105.
Number Needed to Treat To Save A LifeNNTx years = 100 / (% Mortality in Control Group – % Mortality in Treatment Group)
25
147,5
3 411 9
14 1420
2529 29
37
56
0
10
20
30
40
50
60
CARE-HF MUSTT MADIT MADIT II AVID SCD-HeFT SAVE CIBIS II MERIT HF Amiodorone HOPE
CR
T
CR
T-D
CR
T
ICD
Drugs
CRT
Adapted from Auricchio A, Abraham W. Circulation 2004; 109; 300-307.
(1Yr) (3Yr) (5Yr) (2.4Yr) (3Yr) (3Yr) (4Yr) (0.8Yr) (3.5Yr) (1Yr) (1Yr) (1.5Yr) (2Yr) (4 Yr)
COMPANION COPER-NICUS
CAP-RICORN
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– Essentially getting two
therapies for one price• Well below generally accepted
benchmarks for therapeutic interventions of $50,000 - $100,000 per QALY
Feldman AM, et al. J Am Coll Cardiol 2005; 46: 2311 – 2321. [COMPANION sponsored by Guidant]
$19.600
$43.000
$0
$25.000
$50.000
$75.000
CRT-P CRT-D
Benchmark $50,000/QALY
Incremental Cost-Effectiveness Ratios of CRT-P/CRT-D ($/QALY)
Effect of Starting Age and Device Longevity on Cost per QALY – Base case
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
55 60 65 70 75Age at Starting Treatment
Incr
emen
tal C
ost P
er Q
ALY
Gai
ned
€
CRT+MT vs MT CRT+ICD+MT vs CRT + MT CRT+ICD+MT vs MT
8 Years
5 Years7 Years
Conclusions
• Long-term treatment with CRT-P appears highly cost-effective 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
Ermis C Europace 2007Death: 22 vs 14%
≥ 75 Y
INSUFFISANCE CARDIAQUE
AF
Results: Baseline Practice Characteristics
• By Age Tertiles (≤64y, 65-76y, >76y)– Younger patients more likely to attend multispecialty, hospital-
based, 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
Baseline Patient Characteristics by Age Tertile
<.0011.31.21.1Creatinine, median, mg/dL<.001547383254BNP, median, pg/mL<.001136130110QRS duration, median, ms
<.00164%64%58%Hypertension history
<.00141%32%20%Atrial fibrillation history
P>76 y
n=4,79165-76 yn=5,176
≤64 yn=5,307Characteristic
<.00167%73%73%Male<.00173%71%53%Ischemic etiology
<.00129%38%35%Diabetes
<.00142%43%34%Prior MI<.00135%37%22%CABG<.001252525LVEF, median, %
<.001120120120SBP, median, mm Hg<.001262218BUN, median, mg/dL
Yancy CW, et al. Am Heart J 2009;157:754-62
Results: Older Patients Less Likely to Receive Guideline-Indicated HF Therapies
84%90%
46%
71%
39%
52%
66%
80%86%
34%
71%
43%
57%61%
73%
81%
27%
68%
34%
43%
57%
0%
25%
50%
75%
100%< 65y 65-76y >76y
ACEI/ARB Beta-blocker AldosteroneAntagonist
Anticoag.for Atrial Fib.
ICD HFEducation
Cardiac Resynch.
P<.001 P<.001
P<.001
P=.180
P=.028
P<.001P<.001
Elig
ible
pat
ient
s w
ith t
reat
men
t (%
)
Yancy CW, et al. Am Heart J 2009;157:754-62
Results: Significant Differences when Stratified by Age and Sex
47%36% 42%43%
30%37%
0%
50%
100%< 65y 65-76y >76y
Cardiac Resynchronization
Males Females
P=.124 P=.010
50%44%32%34% 27%26%
0%
50%
100%< 65y 65-76y >76y
Males Females
Aldosterone Antagonist
P<.001 P<.001
48%53% 50%59%
32%48%
0%
50%
100%< 65y 65-76y >76y
ICD or CRT-D
Males Females
P<.001 P<.001
• When stratified by age and sex, differences in delivery of guideline-indicated care most striking for:– Aldosterone antagonist;– Cardiac resynchronization (CRT or
CRT-D)– ICD (ICD or CRT-D)
Yancy CW, et al. Am Heart J 2009;157:754-62
Older and Female Patients Less Likely to Receive Some Care Measures
Adjusted odds ratio with 95% CI displayed
Care Measure
ACEI/ARB
ß-Blocker
Aldosterone Antagonist
Anticoagulation for AF*
Cardiac Resynchronization*
HF Education
ICD/CRT-D*
By Increasing Age
0,87
0,85
0,81
0,99
0,88
0,94
0,93
0,1 1 10
By Sex
1,14
0,93
0,79
1,44
1,04
1,42
1,16
0,1 1 10
FemalesMoreLikely
Conformity to Care Measures
MalesMoreLikely
YoungerMoreLikely
OlderMoreLikely
* Significant age and sex interaction
Yancy CW, et al. Am Heart J 2009;157:754-62
(per 10 years)
P<.0001
P<.0001
P<.0001
P=.0233
P<.0001
P=.0023
P=.0199
P=.2400
P=.0358
P=.0001
P=.7702
P<.0001
P=.0010
P=.7767
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
Aspirine: less effect after 75 y
NEJM 2008
SSSAVB
n= 2568
CTOPP
Age moyen: 86.2 ansn: 149
Comparable to data from younger but higher 30 d all cause mortality
JICE 2011
DANPACE 2011n = 1415
AFDEATH
MOST Total Mortality or Stroke
0 6 12 18 24 30 36 42 48 54 600.00
0.10
0.20
0.30
0.40
0.50
Months
Even
t Rat
e
P = 0.48Adjusted P = 0.32
Ventricular pacing
Dual-chamber pacing
Lamas G, et al. N Engl J Med 2002; 346: 1854-62.
No. at risk:Ventricular pacing
Dual-chamber pacing 996 934 897 813 678 557 431 320 218 125 391014 963 930 833 693 555 431 328 214 120 28
MOST MOST ConclusionsConclusions
• In patients with SND, dual-chamber pacing In patients with SND, dual-chamber pacing (versus single-chamber ventricular pacing) (versus single-chamber ventricular pacing) REDUCESREDUCES newly diagnosed and chronic atrial newly diagnosed and chronic atrial fibrillationfibrillation, reduces the signs and symptoms of , reduces the signs and symptoms of heart failure, and slightly improves quality of heart failure, and slightly improves quality of life.life.
• Dual-chamber pacing did Dual-chamber pacing did NOTNOT improve the rate improve the rate of the primary endpoint of of the primary endpoint of mortality or freedom mortality or freedom from strokefrom stroke..
SINUS NODE DISEASE
MOST: n: 2010mean age: 74 (67-80)
NS
DDD
VVI
OR
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation).
Pacemaker ConfigurationsDDD
♀ C. 70 y: recurrent syncope aVR
aVR
aVF
V1
V2
V3
V4
V5
V6
I
II
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
Les stimulateurs cardiaques
Battery
Connector
Hybrid
Telemetry antenna
Output capacitors
Reed (Magnet) switch
Clock
Defibrillation protection
Atrial connector
Ventricular connector
Resistors
Anatomy of a Pacemaker
Kaszala K, Ellenbogen K AJGC 2006
CIRC 2009
ICD AND AGE
CIRC 2009
N= 965
PENGO THROMBOSIS AND HEMOSTASISI 2011
PENGO THROMBOSIS AND HEMOSTASISI 2011