Attitude of Cardiologists on the Use of Invasive Procedures in Frail Older Patients With Coronary Heart Disease in Japan

To the Editor: In Japan, the number of persons aged 65 years and older has increased dramatically, reaching 16.7% of the total population. In addition, a significant increase in the incidence of coronary heart disease (CHD) among older persons has been observed, probably the result of the western influences in the Japanese life style. Recent progress in invasive procedures has improved outcomes among older patients with CHD.1,2 However, although advanced age alone is not a contraindication to the use of effective interventions, older persons have reportedly received less aggressive medical and invasive management.3,4 To date, there are no clear and unifying guidelines for the use of invasive procedures among frail older people. There is however, no, evidence that such procedures improve the quality of life or decrease the mortality of this segment of the population. Hence, the decision to use invasive therapy with frail older people with CHD is up to the cardiologists. To determine the proportion and characteristics of older patients with unstable angina considered eligible for angioplasty by cardiologists, we sent a questionnaire to heads of the department of cardiology of 208 hospitals accredited by the Japan Circulation Society. One hundred four responded between February and March of 1999. Ninety-five of the 104 cited hospitals age as a criteria for angioplasty, and about half of these considered age 85 years and older a contraindication. This was due mostly to frequent association with ADL impairment and increased prevalence of dementia (85%) as well as the presence of greater comorbidity (45%) in this age group. Forty-three percent of hospitals considered patients age to be one of the exclusion criteria for angioplasty, even among patients with no other contraindications. All but one hospital considered ADL impairment a determining factor for doing angioplasty, although the majority answered that a single disability does not constitute a contraindication (Table 1). In only four of the 104 hospitals were patients with dementia eligible, whereas 57 hospitals said that eligibility is dependent on the degree of severity of the dementia. Twenty-four respondents considered dementia to be an absolute contraindication; the others considered it a contraindication dependent on family consent. About 20 to 26% of the total (104) hospitals, and 27 to 35% of the 78 hospitals that considered dementia a contraindication, offered that patients with impaired orientation to place or time, and those with memory loss, are ineligible for the angioplasty procedure (Table 1), About 70% of the total (90% of the 78 hospitals) considered demented patients who have difficulty following instructions ineligible. About 37% of the total (49%/78) considered demented patients who required assistance with ADLs ineligible. Twenty-five percent of the total (33%/78) considered patients with a previous diagnosis of Alzheimer's disease ineligible (Table 1). Ninety-eight percent of the hospitals use anti-platelet drugs for their older patients with CHD in the absence of a bleeding risk, 75% use calcium channel blockers, and 93% used nitrates, but only 38% of the hospitals used beta-blockers for their older patients. About half of the total number of hospitals interviewed revealed that acute myocardial infarction (AMI) rather than unstable angina was the main indication for doing an angioplasty in most older patients in their centers. Forty-eight percent of hospitals do not use thrombolytic therapy among older patients with AMI because of the high risk of bleeding and the higher prevalence of cerebrovascular disease. This survey made clear that most cardiologists in Japan consider ineligible for angioplasty older patients with unstable angina who are frail, who have significant ADL impairment and dementia, who have previously been diagnosed with Alzheimer's disease, and those who have difficulty following instructions and need assistance in their activities of daily living. Older patients are less likely than younger patients to receive beta-blockers but preferably receive anti-platelet drugs, nitrates, and calcium channel blockers. Although consensus has emerged that patient's s age should not be a factor in the decision to use thrombolytic therapy for AMI,5 half of the total respondents would rather not use thrombolytic therapy in older AMI patients. Evidence supporting the effectiveness of invasive procedure in older patients with CHD is mounting.1,2 However, the limitation of these studies is that frail older patients were not included in these trials. Hence, future research should address these issues and determine the role of invasive therapy in older patients who are frail and who have CHD.