Long-term PCI outcomes of elderly

Long-Term Outcomes of PCI Among Elderly and Very Elderly Patients

October 11, 2017

Key Takeaways

  • Assessed outcomes of percutaneous coronary intervention (PCI) among elderly (age 75-80 years, n = 327) and very elderly (>80 years, n = 253) patients.
  • The very elderly group had higher rates of comorbidities compared with the elderly group.
  • The all-cause mortality rate was significantly higher in the very elderly group compared with the elderly group (11.9% vs 6.1%), with no significant difference in cardiac mortality (6.3% vs 3.7%) or major adverse cardiac and cerebrovascular events (16.2% vs 12.5%).

Reference: Gerber RT et al. J Interv Cardiol. 2017.

Elderly patients presenting with complex coronary disease undergoing a percutaneous coronary intervention (PCI) are often faced with multiple challenges.1 First, these patients often have numerous comorbidities which may delay the identification of severe coronary disease, resulting in late intervention.2 Secondly, this patient population often presents with more tortuous vascular anatomy, lower left ventricular function, and more complex calcific coronary disease than younger patients.

Many elderly patients with coronary disease are less likely to receive revascularization, primarily due to the limited enrollment of this population in clinical trials. Current guidelines from the American Heart Association and European Society of Cardiology (ESC) do not include an age limit for PCI in the setting of acute cardiogenic shock; the ESC actually report an invasive strategy and PCI correlate with benefit in elderly patients.3,4 Evidence exists to suggest that reperfusion therapy for older patients may hold benefit.5

Gerber et al performed a comparative analysis of PCI outcomes among two elderly patient cohorts at the East Sussex NHS Trust between 2006 and 2011.6 These two groups included the elderly (age 75-80 years, n = 327) and very elderly (>80 years, n = 253). Primary endpoint was all-cause mortality and occurrence of major adverse cardiac events (MACCE), defined as the composite of cardiac mortality (death due to any cause), myocardial infarction, stroke, target vessel revascularization (TVR), and target lesion revascularization (TLR).

Patients in the very elderly group had higher rates of acute coronary syndrome (ACS) compared with the elderly population (70.3% vs 48.9%, P < 0.001). Additionally, the very elderly group had significantly higher rates of hyperlipidemia (20.9% vs 13.1%, P = 0.01) and renal disease (11.9% vs 5.2%, P <0.01). All-cause mortality was higher in the very elderly cohort (11.9% vs 6.1%, P < 0.05), with no significant difference in MACCE (overall 14.1%).

Primary angioplasty for ST-elevation myocardial infarction using a radial or femoral approach was performed in 94 patients. In this high-risk population, overall MACCE and cardiac mortality was 22% and 16%. The MACCE and the cardiac mortality were both significantly higher in the very elderly group (MACCE: 22% vs 6%, P < 0.05; cardiac mortality: 16% vs 3%, P < 0.05). There was no difference between the two groups in regard to cardiac, all-cause, or in-hospital mortality among patients undergoing elective PCI.

References:

  1. Kaehler J, Meinertz T, Hamm CW. Coronary interventions in the elderly. Heart. 2006;92(8):1167-1171.
  2. Batchelor WB, Anstrom KJ, Muhlbaier LH, et al. Contemporary outcome trends in the elderly undergoing percutaneous coronary interventions: results in 7,472 octogenarians. National Cardiovascular Network Collaboration. J Am Coll Cardiol. 2000;36(3):723-730.
  3. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425.
  4. Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(23):2999-3054.
  5. Shah P, Najafi AH, Panza JA, Cooper HA. Outcomes and quality of life in patients>or=85 years of age with ST-elevation myocardial infarction. Am J Cardiol. 2009;103(2):170-174.
  6. Gerber RT, Arri SS, Mohamed MO, et al. Age is not a bar to PCI: Insights from the long-term outcomes from off-site PCI in a real-world setting. J Interv Cardiol. 2017.

NPS-108-17