Improving heart attack treatments for older patients

Dr Vijay Kunadian is leading a research trial investigating whether standard heart attack treatments still suit patients in their 70s, 80s and 90s. She tells Sarah Brealey about her work.

Dr Vijay Kunadian

You’ve probably heard of an angiogram. It’s a standard test for heart disease that produces X-ray images of your coronary arteries to show where any blockages are. If you’ve had a heart attack, it helps your doctor decide the best course of treatment.

But if you’re over 75, you’re less likely to get an angiogram. And the chances reduce further as you get older – figures from England, Wales and Northern Ireland suggest that only 14 per cent of heart attack patients aged 85 or older have an angiogram, compared with 83 per cent of under-65s.

That means you won’t be able to have procedures, such as angioplasty and stent or bypass surgery that restore blood flow to the heart, because these can’t usually be done without an angiogram.

So is this age discrimination or a sensible approach? There are some risks involved with an angiogram, which involves a thin flexible tube being inserted into your wrist or groin and passed through to the heart. These risks, such as bleeding or injury to blood vessels, can be more common in older people. But we don’t know whether the risks outweigh the benefits. The BHF is helping Dr Vijay Kunadian find the answer.

Investigating how to help older heart attack patients

“People are surviving longer and this means heart disease is able to affect more people later in life, and they are more likely to have other conditions too,” explains Dr Kunadian. “We need definitive answers about how to treat them.”

Dr Kunadian is a Consultant Interventional Cardiologist at the Freeman Hospital in Newcastle, alongside her academic post as Senior Lecturer in the Institute of Cellular Medicine at Newcastle University. “When I was a junior doctor training as a cardiologist, most, if not all, of my heart attack patients were in their 40s, 50s or 60s,” she says.

We would not be running this study without the BHF. I am delighted that the BHF has recognised that this is a crucial research question

"I did some research training at Harvard and, when I returned to the UK, on my first day as a consultant cardiologist every one of my patients on the angiogram list was born in the 1930s. It was literally four or five patients in a row who were 85 or older.

"I was thinking: ‘A lot of these patients have other health conditions and some of them are quite frail. There is very little research on how to help these patients.’”

She has already carried out a small study of older patients in Newcastle, but needs to get a wider sample of patients to be sure about the findings. “We put in an application to the BHF and were delighted that we were given a grant for a UK-wide trial,” she says.

Thanks to money raised by BHF supporters, we are funding the trial with £1.7m. Dr Kunadian says: “We would not be running this very important study without the BHF. I am delighted that the BHF has recognised that this is a crucial research question.”

Types of heart attack

Dr Kunadian is studying non-STEMI heart attacks. Around 60 per cent of heart attacks in the UK are non-STEMI and they are more likely to occur in older patients – half of non-STEMI heart attacks are in patients aged 72 or older. It usually means a coronary artery is partly blocked (rather than completely blocked, as it is in a STEMI heart attack).

In the medium to long term, non-STEMI patients are more likely to experience further heart attacks or die. National guidelines recommend that non-STEMI patients should have an angiogram within 72 hours of admission to hospital. But this only happens in just over half of cases in the UK – and for the oldest patients, it’s even less.

Dr Kunadian’s research has the potential to make a real difference.

Dr Vijay Kunadian

Building on previous BHF research

Dr Kunadian’s research builds on the work of BHF Professor Keith Fox, who led the largest ever heart attack study, looking at more than 102,000 patients. He also led a groundbreaking study to look at the safety of angioplasty and stents, called the RITA trial, so Dr Kunadian has christened her study the SENIOR-RITA trial.

I have never been bored with cardiology. Heart disease is such a big problem. As soon as you find one answer, something else comes up

“Keith Fox’s well-known RITA study looked at patients with an average age of 62,” she says. “That was appropriate then, because those were the patients we were seeing, but we don’t know whether these findings are applicable in older patients who may have other conditions too.”

The trial will focus on patients over 75 who’ve had the most common type of heart attack, called a non-STEMI or nSTEMI. Patients who agree to be enrolled in the study are randomly chosen to receive either:

  • an angiogram followed by whatever treatments are judged appropriate (this could be angioplasty, heart bypass surgery or medication), or
  • no angiogram, but all appropriate heart medications instead.

Patients will be followed up for five years, to see which group has better rates of survival and lower rates of recurring heart attack problems. This will include looking at the risk of complications, quality of life and cost-effectiveness of the treatments.

Investigating the heart and the brain

Dr Kunadian is already thinking about what’s next in her research. She wants to study how problems with your heart could affect your brain, too. “Half of these older non-STEMI patients have some cognitive decline within the first year [after the heart attack],” she says. “I want to look at the causes of this. We will use high-tech scans of the heart and brain.”

She adds: “I have never been bored with cardiology. Heart disease is such a big problem. As soon as you find one answer, something else comes up. I want to know the answers to these questions for my patients. That is what keeps me excited and engaged.”

How can you help the research?

Dr Kunadian is still looking for hospitals to take part in the trial, and wants patients to say yes if they are offered the chance to be involved. “We hope to have 30–40 sites across the UK, in England, Scotland, Wales and hopefully Northern Ireland too,” says Dr Kunadian.

“This will be the largest study ever conducted. We want every clinician dealing with over-75s with non-STEMI to think about this trial.”

For the trial to be accurate, patients’ treatment must be randomly allocated, so the results aren’t influenced by which patients are put forward for which treatment. This means it’s not the kind of trial you can volunteer for – your hospital must already be taking part, then you’ll be offered the opportunity to get involved if you’re diagnosed with a non-STEMI and you are over 75.

Dr Kunadian says: “Sometimes the doctors decide they want to make the decision but we are asking them to consider presenting the study to the patients. We will do everything in the best interests of the patient. We will find out how to best handle these patients in the future.”

If you’re interested in taking part in other research studies, visit the UK Clinical Trials Gateway website. If you don’t have internet access, try asking your GP or cardiologist if there are other trials you can take part in.


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