Two problems predominate in elderly patients with heart disease: chronic coronary artery disease (CAD) and chronic congestive heart failure (CHF). We addressed both of these problems in two separate prospective randomised multicentre management trials. The findings of these studies are discussed in the light of other randomised controlled trials on the treatment of chronic CAD and intensified hormone-based CHF therapy. The implications are that elderly patients should be offered invasive evaluation and revascularisation if their symptom/ischaemic risk is high and coronary anatomy suitable for revascularisation. They will benefit from rapid symptom relief and improvement in quality of life. Alternatively, they could be managed with optimal drug therapy only and undergo invasive evaluation and revascularisation if medical management fails, as will be the case in a third to half of patients. In contrast, elderly patients with CHF will not benefit from intensified treatment as younger patients do. Thus, the findings suggest that specific CHF trials in elderly patients are warranted to obtain a better definition of their treatment options, which seem more limited than in younger patients.
According to Swiss federal statistics, life expectancy has increased tremendously in Switzerland during the last 35 years: for women from about 76 years in 1970 to 84 years in 2006, and for men from 70 to 79.1 years during the same time period [1]. Thus, the number of elderly Swiss inhabitants, particularly those aged ≥75 years, has risen sharply. The leading cause of death in Switzerland in 2006 was still “cardiovascular” for women (39.5%) and men (34.6%) [1] and again this was even more so in patients aged ≥75 years. Among these cardiovascular deaths, those due to coronary artery disease (CAD) are by far the most prominent. In addition, CHF or end-stage heart failure was a main reason for morbidity associated with frequent hospitalisations and dependence on medical treatment [2]. Thus, CAD and CHF represent the most important challenges in the aging population, for whichthere is a lack of randomised controlled trial data [3].
The TIME studies were therefore initiated as prospective multicentre trials to assess whether an intensified invasive or hormone-guided treatment strategy would yield an outcome benefit in elderly patients with CAD or CHF: the Trial of Invasive versus Medical Therapy in Elderly Patients with Chronic CAD (TIME; 4) and the Trial of Intensified BNP-guided versus standard symptom-guided Medical Therapy in Elderly Patients with Congestive Heart Failure (TIME-CHF, 5).
The aim of the present report is to summarise the most important results of these two trials and to compare findings with other similar studies in patients with chronic CAD and CHF respectively. This should have reasonable management implications for elderly patients with chronic angina or dyspnoea due to heart failure.
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