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Commentary
Primary Angioplasty in the Very Elderly — How Old Is Too Old?
October 2010
Acute myocardial infarction is the leading cause of death in elderly patients,1 and cardiologists are increasingly confronted with the management of elderly patients presenting with ST-elevation myocardial infarction (STEMI). In fact, patients over the age of 85 represent the fastest-growing population in the U.S.2 It is estimated that by the year 2030, 20% of the population will be over the age of 65 and that by 2050, those over age 65 will outnumber their younger counterparts.3 Optimal management of acute coronary syndromes in this population has been an area of uncertainty as there is a paucity of evidence-based data due to their exclusion and underrepresentation in clinical trials.4 Data from the Global Utilization of Streptokinase and Tissue Plasminogen Activator To treat Occluded Arteries (GUSTO 1) trial demonstrated the 30-day mortality rate for STEMI increased 10-fold among the elderly, from 3.0% in the age group of 85 years of age.5 This high mortality rate in the very elderly was confirmed by multiple similar studies,1,3,6 emphasizing the need for more effective therapies.
Despite clear evidence of benefit with coronary revascularization in the setting of acute coronary syndromes,7–9 it appears that many of the treatment recommendations are underutilized in the elderly and even more so in the very elderly. They are less likely to be evaluated by a cardiologist10 or to receive guideline-recommended therapies which have proven mortality benefit.2,10,11 The decision for aggressive revascularization in the elderly may be tempered by the patient’s comorbidities, age bias, concerns over increased mortality and concerns for bleeding complications with aggressive anticoagulation therapy.
Various factors may contribute to increased mortality in the elderly population. Elderly patients are more prone to delayed presentation after symptom onset due to failure to associate their symptoms as an ischemic manifestation requiring prompt medical attention. Socioeconomic and cognitive factors may also play a role in delayed presentation.12 Recently, Stone et al highlighted the importance of time to presentation in 4,548 randomized patients by reporting that delayed presentation (> 90 minutes) abrogated the mortality benefit of guideline-recommended door-to-balloon time.13 Even after seeking medical attention, the elderly population presents a diagnostic challenge leading to additional delays as they are less likely to present with ST elevations on electrocardiography (ECG) and more likely to have silent ischemia or abnormal ECGs at baseline.12 The elderly may also experience higher mortality from STEMI due to numerous and more severe comorbidities, advanced coronary artery disease (frequently 3-vessel disease), as well as mechanical and electrical complications of acute MI.1,12,14
Among nonagenarians presenting with acute MI, mortality is even further increased.1 One of the largest cohorts studied from the CRUSADE initiative involving 5,557 nonagenarians demonstrated significantly higher morbidity and mortality rates in nonagenarians with acute coronary syndrome compared to the 75–89 years age group. Part of the reason for the observed 23% relative increase in mortality among nonagenarians could be the less aggressive management of this cohort. In fact, nonagenarians were less likely to receive guideline-recommended therapy like glycoprotein IIb/IIIa inhibitors and statins during the first 24 hours and cardiac catheterization. Importantly, increasing adherence to guideline-recommended therapies was associated with a graded reduction in risk-adjusted in-hospital mortality in both the elderly and nonagenarian groups.10
In the current issue of the Journal, Ionescu et al endeavor to expand our knowledge of STEMI outcomes among nonagenarians.16 This retrospective analysis of 24 nonagenarians confirmed many previous findings, including the frequency of late presentation in this age group (less than a third of patients presented within 6 hours of symptom onset). In all, 46% of patients were treated medically and 54% with percutaneous coronary intervention (PCI). The study clearly demonstrates a significant mortality benefit in favor of PCI (hazard ratio 3.28, 95% confidence interval 1.09–9.92; p = 0.035) in patients presenting within 6 hours of symptom onset. In accordance with Stone et al,13 no mortality benefit was evident in patients receiving PCI after 6 hours of symptom onset. Of note, only 1 patient in the medical arm presented within 6 hours of presentation in a comatose state after cardiac arrest. Despite the frequent late presentation and the numerous comorbidities increasing PCI risk, the study confirmed a very high procedural success rate in this elderly population undergoing PCI, as reported in prior studies.14,15 The authors acknowledge limitations of the study including selection bias and the lack of dual antiplatelet therapy in the medical treatment arm.
With an increasingly aging population at high risk for adverse cardiovascular events from STEMI, clearly a more sophisticated and effective clinical strategy is needed. Based on current evidence, we agree with the study that nonagenarians presenting within 6 hours of symptom onset should be strongly considered for primary angioplasty over medical therapy despite the substantially higher mortality risk in this population. However, it has also been clearly demonstrated that the elderly derive more absolute benefit from PCI. We advocate for careful consideration of the elderly for primary PCI by determination of the appropriateness of revascularization, taking into account variables including the presence of life-limiting comorbidities, functional status, patient preferences, time from onset of symptoms to presentation, overall clinical stability and feasibility of technical success. Judicious assessment of revascularization candidacy in the elderly may lead to more favorable clinical outcomes while minimizing procedure-related complications. Further studies are required to incorporate evidence-based medicine into the management of STEMI in this high-risk population. Other strategies to improve outcomes may include a shift to radial access to minimize procedure-related bleeding complications, patient education to reduce presentation times and physician education to raise awareness of atypical presentations of ACS in this population.
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From the Department of Medicine, Division of Cardiovascular Medicine, Stony Brook University Medical Center, Stony Brook, New York.
The authors report no conflicts of interest regarding the content herein.
Address for correspondence: Allen Jeremias, MD, MSc, Division of Cardiovascular Medicine, Stony Brook University, Health Sciences Center T 16-080, Stony Brook, NY 11794-8171. E-mail: allen.jeremias@stonybrook.edu
