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Ticagrelor Use and the “Treatment Risk Paradox” in Elderly Patients With Acute Coronary Syndromes
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Abstracts
men (71% vs 85% p = 0.03). There was no difference in statin intensity on admission between pre and post interventional groups, and only 8% overall were on high intensity therapy. There was a significant increase in the prescription of high intensity statin therapy post intervention. Conclusion: We found low rates of guideline, high intensity statin prescribing following acute coronary syndromes. After a simple educational intervention this was significantly improved. References [1] Stone NJ, et al. ACC/AHA Blood Cholesterol Guideline 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adult. Circulation 2013. 2013; 01. [2] Schwartz GG, et al. Effects of Atorvastatin on Early Recurrent Ischemic Events in Acute Coronary Syndromes: The MIRACL Study: A Randomized Controlled Trial. JAMA 2001;285(13):1711–8. 4. [3] Weng T-C, Yang Y-HK, Lin S-J, Tai S-H. A systematic review and metaanalysis on the therapeutic equivalence of statins. Journal of Clinical Pharmacy and Therapeutics 2010;35:139–51.
http://dx.doi.org/10.1016/j.hlc.2017.05.017 O17 Ticagrelor Use and the “Treatment Risk Paradox” in Elderly Patients With Acute Coronary Syndromes Ben Wilkins 1*, Phillip Matsis 1, Mark Simmonds 1, Ana Holley 2, Peter Larsen 3, Scott Harding 1 1
Capital and Coast District Health Board, Wellington, New Zealand 2 University of Victoria, Wellington, New Zealand 3 University of Otago, Wellington, New Zealand * Corresponding author. Background: The elderly are a high-risk group subject to a “treatment-risk paradox” in that they tend to receive paradoxically less aggressive evidence-based secondary prevention than younger, lower risk patients. Ticagrelor has been shown to reduce death and vascular events in acute coronary syndrome (ACS) when compared to clopidogrel. This study examined the use of ticagrelor in the elderly. Methods: We studied discharge prescriptions and 1-year outcomes in a prospective cohort of 1100 patients admitted to Wellington Hospital with ACS, including 186 patients aged 75 years. Results: In those under 75, 33.5% were prescribed ticagrelor compared to 17.2% of those 75 (p = 0.0001). Elderly patients had higher risk (GRACE scores mean 151 compared to 119 in under 75, p < 0.0001), and consistent with this had a higher rate of major adverse cardiac events (composite of death, MI, stroke and unplanned revascularisation) (13.4% vs. 8.1%, p = 0.03). There was no difference in bleeding risk between the two age groups (CRUSADE bleeding risk mean 21.9 in those 75 vs. 21.8 in under 75, p = 0.8). TIMI major bleeding was rare (3 cases in the elderly, 2 in those under 75) and TIMI minor bleeding was more common in the elderly (11.8% vs. 7.3% p = 0.045). There was no association between bleeding and choice of antiplatelet agent. Conclusion: Elderly patients with ACS are at higher risk of adverse events and have worse outcomes at 1 year. Prescription rates of ticagrelor remain low in this population who
potentially to have the most to gain from optimised antiplatelet therapy. http://dx.doi.org/10.1016/j.hlc.2017.05.018
Heart Failure O18 Trastuzumab Cardiotoxicity: Incidence, Risk Factors and the Role of Cardiac Monitoring – The Auckland City Hospital Experience Mohammed Alawami *, Gary Lau, Ivor Gerber Auckland City Hospital, Auckland, New Zealand Corresponding author.
*
Aim: Trastuzumab is used in the treatment of breast cancer in a selected group of patients. Early studies have reported trastuzumab associated cardiotoxicity. We aim to identify the incidence and risk factors associated with left ventricular ejection fraction (LVEF) changes in this group and review the monitoring protocol. Method: Retrospective review of all patients receiving trastuzumab therapy and had serial echocardiography at Auckland City Hospital between 1 January 2015 and 31 December 2016 were included in this study. Baseline LVEF and changes during treatment were analysed. Results: 295 patients were included (mean: age 54 12 years, BMI 29 7; 21% hypertension, 11% diabetic). 76% had history of anthracycline exposure. Four patients had known ischaemic heart disease or haemodynamically significant valvular heart disease. 1125 echocardiograms were performed as part of the monitoring protocol (average 3.8 echocardiograms per-patient). Mean follow-up was 371 days. LVEF decrease of 10% occurred in 33 patients (11.1%), including 11 (3.7%) patients with LVEF decrease below 50%. Two patients developed acute heart failure due to trastuzumab. No death due to heart failure was recorded. The only significant predictor for LVEF decrease of 10% during treatment was anthracycline exposure (p = 0.029). Conclusion: Sub-clinical decrease in LVEF occurred in 11.1%. A decrease in LVEF to <50% occurred uncommonly and clinically apparent heart failure occurred rarely. The only significant predictor for LVEF drop during treatment was anthracycline exposure. Management of this higher risk cohort merits further study. http://dx.doi.org/10.1016/j.hlc.2017.05.019
O19 Acute Decompensated Heart Failure: Identifying Gaps to Bridge Mayanna Lund 1*, Helen McGrinder 2, Marisa van Arragon 2, Andrew Kerr 1,3 1
Middlemore Hospital, Auckland, New Zealand Auckland District Health Board, Auckland, New Zealand 3 University of Auckland, Auckland, New Zealand * Corresponding author. 2
Abstracts
men (71% vs 85% p = 0.03). There was no difference in statin intensity on admission between pre and post interventional groups, and only 8% overall were on high intensity therapy. There was a significant increase in the prescription of high intensity statin therapy post intervention. Conclusion: We found low rates of guideline, high intensity statin prescribing following acute coronary syndromes. After a simple educational intervention this was significantly improved. References [1] Stone NJ, et al. ACC/AHA Blood Cholesterol Guideline 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adult. Circulation 2013. 2013; 01. [2] Schwartz GG, et al. Effects of Atorvastatin on Early Recurrent Ischemic Events in Acute Coronary Syndromes: The MIRACL Study: A Randomized Controlled Trial. JAMA 2001;285(13):1711–8. 4. [3] Weng T-C, Yang Y-HK, Lin S-J, Tai S-H. A systematic review and metaanalysis on the therapeutic equivalence of statins. Journal of Clinical Pharmacy and Therapeutics 2010;35:139–51.
http://dx.doi.org/10.1016/j.hlc.2017.05.017 O17 Ticagrelor Use and the “Treatment Risk Paradox” in Elderly Patients With Acute Coronary Syndromes Ben Wilkins 1*, Phillip Matsis 1, Mark Simmonds 1, Ana Holley 2, Peter Larsen 3, Scott Harding 1 1
Capital and Coast District Health Board, Wellington, New Zealand 2 University of Victoria, Wellington, New Zealand 3 University of Otago, Wellington, New Zealand * Corresponding author. Background: The elderly are a high-risk group subject to a “treatment-risk paradox” in that they tend to receive paradoxically less aggressive evidence-based secondary prevention than younger, lower risk patients. Ticagrelor has been shown to reduce death and vascular events in acute coronary syndrome (ACS) when compared to clopidogrel. This study examined the use of ticagrelor in the elderly. Methods: We studied discharge prescriptions and 1-year outcomes in a prospective cohort of 1100 patients admitted to Wellington Hospital with ACS, including 186 patients aged 75 years. Results: In those under 75, 33.5% were prescribed ticagrelor compared to 17.2% of those 75 (p = 0.0001). Elderly patients had higher risk (GRACE scores mean 151 compared to 119 in under 75, p < 0.0001), and consistent with this had a higher rate of major adverse cardiac events (composite of death, MI, stroke and unplanned revascularisation) (13.4% vs. 8.1%, p = 0.03). There was no difference in bleeding risk between the two age groups (CRUSADE bleeding risk mean 21.9 in those 75 vs. 21.8 in under 75, p = 0.8). TIMI major bleeding was rare (3 cases in the elderly, 2 in those under 75) and TIMI minor bleeding was more common in the elderly (11.8% vs. 7.3% p = 0.045). There was no association between bleeding and choice of antiplatelet agent. Conclusion: Elderly patients with ACS are at higher risk of adverse events and have worse outcomes at 1 year. Prescription rates of ticagrelor remain low in this population who
potentially to have the most to gain from optimised antiplatelet therapy. http://dx.doi.org/10.1016/j.hlc.2017.05.018
Heart Failure O18 Trastuzumab Cardiotoxicity: Incidence, Risk Factors and the Role of Cardiac Monitoring – The Auckland City Hospital Experience Mohammed Alawami *, Gary Lau, Ivor Gerber Auckland City Hospital, Auckland, New Zealand Corresponding author.
*
Aim: Trastuzumab is used in the treatment of breast cancer in a selected group of patients. Early studies have reported trastuzumab associated cardiotoxicity. We aim to identify the incidence and risk factors associated with left ventricular ejection fraction (LVEF) changes in this group and review the monitoring protocol. Method: Retrospective review of all patients receiving trastuzumab therapy and had serial echocardiography at Auckland City Hospital between 1 January 2015 and 31 December 2016 were included in this study. Baseline LVEF and changes during treatment were analysed. Results: 295 patients were included (mean: age 54 12 years, BMI 29 7; 21% hypertension, 11% diabetic). 76% had history of anthracycline exposure. Four patients had known ischaemic heart disease or haemodynamically significant valvular heart disease. 1125 echocardiograms were performed as part of the monitoring protocol (average 3.8 echocardiograms per-patient). Mean follow-up was 371 days. LVEF decrease of 10% occurred in 33 patients (11.1%), including 11 (3.7%) patients with LVEF decrease below 50%. Two patients developed acute heart failure due to trastuzumab. No death due to heart failure was recorded. The only significant predictor for LVEF decrease of 10% during treatment was anthracycline exposure (p = 0.029). Conclusion: Sub-clinical decrease in LVEF occurred in 11.1%. A decrease in LVEF to <50% occurred uncommonly and clinically apparent heart failure occurred rarely. The only significant predictor for LVEF drop during treatment was anthracycline exposure. Management of this higher risk cohort merits further study. http://dx.doi.org/10.1016/j.hlc.2017.05.019
O19 Acute Decompensated Heart Failure: Identifying Gaps to Bridge Mayanna Lund 1*, Helen McGrinder 2, Marisa van Arragon 2, Andrew Kerr 1,3 1
Middlemore Hospital, Auckland, New Zealand Auckland District Health Board, Auckland, New Zealand 3 University of Auckland, Auckland, New Zealand * Corresponding author. 2