Percutaneous Coronary Intervention in the Very Elderly: Do Nonagenarians Have the Most to Gain or the Most to Lose?

The elderly are often poorly represented in major clinical trials of percutaneous coronary intervention (PCI).¹ An exact definition for “elderly” varies; for instance, the 2002 ACC/AHA practice guideline for the management of acute coronary syndromes considered patients ≥75 as a special “at-risk” group.² Many clinical trials exclude patients over 75. Older cohorts are considered to have lower overall life expectancy, and numerous comorbidities that may contribute to adverse events unrelated to the therapy under investigation. In those trials where certain elderly patients are included, those patients may not be representative of typical individuals in their age range.

Despite overall increased hospital mortality compared to younger patients, the elderly may sustain more benefit than younger patients when treated with guideline-based therapies.³ Hence, a signal for treatment of acute coronary syndromes (ACS) remains evident despite the common concerns of being too “aggressive” with older patients.

Ischemic heart disease is the most common worldwide cause of death in patients greater than 65 years old. With an aging population in the United States, the number of patients with heart disease will only continue to grow.⁴ As a complement to diagnostic and medical therapies, the role of PCI in the management of elderly patients will require further clarification. PCI can be technically successful in octagenarians for both ACS and elective scenarios.⁵ Additionally, in older individuals with acute myocardial infarction, primary PCI remains associated with a lower risk of death, stroke, or repeat revascularization rates at 30 days compared to a fibrinolytic-based strategy.⁶ Nevertheless, very elderly individuals undergoing emergent PCI do suffer from higher mortality.⁷ In comparison, nonagenarians demonstrate excellent responses to PCI in non-emergent settings.⁸ Data from the last decade describe procedural success of over 90% in the nonagenarian population and a similar mortality rate for age-matched controls.⁹ The use of drug-eluting stents has been shown to be safe in this age group when patients presenting in a state of extremis are excluded and high procedural success is achieved.¹⁰

In the current issue of the Journal, Hendler et al demonstrated 30-day outcomes for nonagenarians undergoing PCI for both acute coronary syndromes and for elective treatment of stable angina over a 9-year period.¹⁰ In this study of 45 people over 90 years old, patients were analyzed according to clinical indication for PCI therapy. The subjects were divided into ST-elevation myocardial infarction (STEMI), unstable angina/non-STEMI, and stable angina subgroups. Their analysis included 15 women (33%), 17 patients with prior MI (38%), and 18 patients (40%) with a history of severe left ventricular dysfunction (LVEF <35%) and elevated Killip class on presentation. Surprisingly, none of the patients had received prior PCI. In the 8 patients receiving primary PCI, all patients were seen to have multivessel CAD, and the majority (57.9%) suffered anterior wall STEMI. When considering the total study population, most patients had PCI performed to one vessel (35 patients; 78%), and left main angioplasty was performed in 5 patients (40%).

In terms of outcomes, the authors observed mortality only in STEMI patients, with 5 deaths (11%) at 30 days compared to no deaths in the remaining patients (P=.04). Periprocedural outcomes were notable for cerebrovascular events in 2 patients (4.5%) versus 1 patient (2.7%) in the STEMI and UA/non-STEMI/stable angina groups, respectively (P=.08). Comorbid conditions identified in the 5 patients who died included Killip class >2 (80%), cardiogenic shock (80%), prior CABG (40%), severe left ventricular dysfunction (40%), and chronic renal insufficiency (80%).

The findings of this study are supported by prior publications demonstrating a higher mortality rate in nonagenerians who receive primary PCI in the setting of cardiogenic shock.^3,8,12 In fact, presentation with cardiogenic shock remains as strong predictor of 6-month mortality in this populace of aged individuals (hazard ratio, 10.92; 95% confidence interval, 4.51-25.93; P<.001).¹²

In looking forward, it is reasonable to assert that in 2011, PCI remains a viable option for those in their 90s who have some spark left in them. Clinicians are well-aware of a whole host of features, some measurable and some not, that contribute to the decision process to offer PCI to a patient. It should be noted that even in a highly selected cohort, patients in their 90s can achieve high technical success rates when undergoing PCI. Considering these facts, we look forward to future datasets that may employ strategies to improve the safety profile of PCI including tailored anticoagulation regimens, alternative access sites, and the use of vascular access closure devices.^13,14 Finally, the present study by Hendler et al continues to suggest that PCI can be performed in a very elderly population with reasonable success, but short-term adverse event rates including mortality are not trivial. Careful consideration of the “big picture” is critical in this cohort.

References

1. Lee PY, Alexander KP, Hammill BG, Pasquali SK, Peterson ED. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA. 2001;286(6):708-713.
2. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction — 2002: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circulation. 2002;106(14):1893-1900.
3. Skolnick AH, Alexander KP, Chen AY, et al. Characteristics, management, and outcomes of 5557 patients age > or = 90 years with acute coronary syndromes: results from the CRUSADE initiative. J Am Coll Cardiol. 2007;49(17):1790-1797.
4. Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: non-ST segment elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115(19):2549-2569.
5. McKellar SH, Brown ML, Frye RL, Schaff HV, Sundt TM 3rd. Comparison of coronary revascularization procedures in octogenarians: a systematic review and meta-analysis. Nat Clin Pract Cardiovasc Med. 2008;5(11):738-746.
6. de Boer MJ, Ottervanger JP, van’t Hof AW, Hoorntje JC, Suryapranata H, Zijlstra F. Reperfusion therapy in elderly patients with acute myocardial infarction: a randomized comparison of primary angioplasty and thrombolytic therapy. J Am Coll Cardiol. 2002;39(11):1723-1728.
7. Merchant FM, Weiner RB, Rao SR, et al. In-hospital outcomes of emergent and elective percutaneous coronary intervention in octogenarians. Coron Artery Dis. 2009;20(2):118-123.
8. Teplitsky I, Assali A, Lev E, Brosh D, Vaknin-Assa H, Kornowski R. Results of percutaneous coronary interventions in patients > or = 90 years of age. Catheter Cardiovasc Interv. 2007;70(7):937-943.
9. From AM, Rihal CS, Lennon RJ, Holmes DR Jr, Prasad A. Temporal trends and improved outcomes of percutaneous coronary revascularization in nonagenarians. JACC Cardiovasc Interv. 2008;1(6):692-698.
10. Lee MS, Zimmer R, Pessegueiro A, Jurewitz D, Tobis J. Outcomes of nonagenarians who undergo percutaneous coronary intervention with drug-eluting stents. Catheter Cardiovasc Interv. 2008;71(4):526-530.
11. Hendler A, Katz M, Gurevich Y, et al. 30-day outcome after percutaneous coronary angioplasty in nonagenarians: feasibility and specific considerations in different clinical settings. J Invasive Cardiol. 2011;23(12):521-524.
12. Danzi GB, Centola M, Pomidossi GA, et al. Usefulness of primary angioplasty in nonagenarians with acute myocardial infarction. Am J Cardiol. 2010;106(6):770-773.
13. Marso SP, Amin AP, House JA, et al. Association between use of bleeding avoidance strategies and risk of periprocedural bleeding among patients undergoing percutaneous coronary intervention. JAMA. 2010;303(21):2156-2164.
14. Koutouzis M, Matejka G, Olivecrona G, Grip L, Albertsson P. Radial vs. femoral approach for primary percutaneous coronary intervention in octogenarians. Cardiovasc Revasc Med. 2010;11(2):79-83.

________________________________________

From the University of Illinois Chicago, Chicago, Illinois.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Shroff discloses that he is a consultant for Terumo Medical, Teleflex, Abiomed, and the Medicines Company.
Address for correspondence: Dr. Dean Ferrera, University of Illinois – Chicago and Jesse Brown VA Medical Center, 840 S Wood St, MC 715, Chicago, IL 60607. Email: dferrera@uic.edu