Initial and long-term results of percutaneous transluminal coronary angioplasty in patients 75 years of age and older

Acute and intermediate‐term results of percutaneous coronary stenting in octogenarian patients

BACKGROUND

Percutaneous coronary intervention (PCI) in octogenarian patients has been associated with increased cardiovascular morbidity and mortality. This study aimed to assess acute and intermediate-term clinical outcomes among octogenarians undergoing PCI.

METHODS

The authors identified 97 consecutive patients aged > or =80 years who underwent PCI using stents between November 2000 and February 2002 at their institution. The patients were divided into three groups according to clinical presentation: (1) acute myocardial infarction (AMI, n = 31); (2) unstable angina pectoris (UAP, n = 28); and (3) stable angina pectoris (SAP, n = 38). Procedural data, and in-hospital and six-month clinical outcomes were obtained and adjudicated for all patients.

RESULTS

Overall mean age was 84 +/- 3 years, 67% of patients were males and 73% had multivessel coronary disease. In-hospital outcomes varied according to clinical presentation: procedural success was 78% in AMI patients (including shock patients), 93% in UAP, and 95% in SAP patients. Likewise, hospital mortality was 26% in AMI, 3.6% in UAP, and 0% in SAP patients (p = 0.0003). Among AMI patients, hospital mortality was extremely high in patients with cardiogenic shock (67% versus 4.6% in AMI without shock, p < 0.0001). Cumulative event rate at six months also varied according to clinical presentation: mortality/MI and target vessel revascularization (TVR) rates were 29%, 3.6%, and 0% in AMI, 7.1%, 7.4%, and 11% in UAP and 0%, 5.3%, and 7.9% in SAP patients. Multivariate analysis identified cardiogenic shock as the most powerful risk factor for predicting mortality (odds ratio = 42, p = 0.03).

CONCLUSIONS

These results show that clinically stable octogenarian patients undergoing PCI have favorable procedural and intermediate-term prognosis. In contrast, cardiogenic shock has a profound negative prognostic impact on octogenarians despite 'aggressive' PCI attempts.

Long-term clinical outcome of coronary artery stenting in elderly patients

BACKGROUND

The elderly constitute a rapidly expanding segment of our population and cardiovascular disease becomes more prevalent with increasing age. Existing data have shown that percutaneous coronary interventions in the elderly are associated with an increase risk of in-hospital complications compared to younger patients. In the present study we retrospectively assessed the long-term clinical outcome of coronary artery stenting in an elderly population and compared them with the cohort of younger patients.

METHODS

The study population included 402 consecutive patients with coronary artery disease who underwent coronary artery stenting; of these 69 were elderly (age > 70 years, group I) and 333 were younger (age <or= 70 years, group II). Percutaneous coronary intervention combined with stent implantation was performed using standard techniques. Clinical outcomes during follow-up (24 +/- 13 months, range 7-56 months) were obtained in all patients without major in-hospital complications. Survival curves and multivariate Cox proportional hazard models for any late clinical event were reported.

RESULTS

No difference in in-hospital complications or clinical success rate was observed between the two groups of patients. Complete revascularization was obtained more frequently in younger compared to elderly patients (P < 0.05). At 2 years, event-free survival was 62% in the elderly and 76% in younger patients (P < 0.001); this difference was mostly made-up by recurrence of angina in the elderly. Impaired left ventricular systolic function (ejection fraction < 40%) was an independent predictor of late death.

CONCLUSIONS

Coronary artery stenting is an effective therapeutic strategy in elderly with coronary artery disease and is associated with good short- and long-term results. Age per se should not preclude patients from undergoing coronary stenting.

Contemporary outcome trends in the elderly undergoing percutaneous coronary interventions: results in 7,472 octogenarians. National Cardiovascular Network Collaboration

OBJECTIVES

We sought to define the risks facing octogenarians undergoing contemporary percutaneous coronary interventions (PCIs).

BACKGROUND

The procedural risks of PCI for octogenarians have not been well established.

METHODS

We compared the clinical characteristics and in-hospital outcomes of 7,472 octogenarians (mean age 83 years) with those of 102,236 younger patients (mean age 62 years) who underwent PCI at 22 National Cardiovascular Network (NCN) hospitals from 1994 through 1997.

RESULTS

Octogenarians had more comorbidities, more extensive coronary disease and a two- to fourfold increased risk of complications, including death (3.8% vs. 1.1%), Qwave myocardial infarction (1.9% vs. 1.3%), stroke (0.58% vs. 0.23%), renal failure (3.2% vs. 1.0%) and vascular complications (6.7% vs. 3.3%) (p < 0.001 for all comparisons). Independent predictors of procedural mortality in octogenarians included shock (odds ratio [OR] 5.4, 95% confidence interval [CI] 3.3 to 8.8), acute myocardial infarction (OR 3.2, 95% CI 2.3 to 4.4), left ventricular ejection fraction (LVEF) <35% (OR 2.9, 95% CI 2.1 to 3.9), renal insufficiency (OR 2.8, 95% CI 2.0 to 3.8), first PCI (OR 2.3, 95% CI 1.7 to 3.3), age >85 years (OR 2.1, 95% CI 1.5 to 2.7) and diabetes mellitus (OR 1.5, 95% CI 1.1 to 2.0). For elective procedures, octogenarian mortality varied nearly 10-fold, and was strongly influenced by comorbidities (0.79% mortality with no risk factors vs. 7.2% with renal insufficiency or LVEF <35%). Despite similar case-mix, PCI outcomes in octogenarians improved significantly over the four years of observation (OR of 0.61 for death/myocardial infarction/stroke in 1997 vs. 1994; 95% CI 0.45 to 0.85).

CONCLUSIONS

Risks to octogenarians undergoing PCI are two- to fourfold higher than those of younger patients, strongly influenced by comorbidities, and have decreased in the stent era.

Effect of coumarins started before coronary angioplasty on acute complications and long-term follow-up: a randomized trial

BACKGROUND

Coronary angioplasty frequently creates a thrombogenic surface, with subsequent mural thrombosis that may lead to acute complications and possibly stimulates the development of restenosis. Whether coumarins can prevent these complications is unclear. The objective of this open, randomized trial was to assess the clinical effect of coumarins started before coronary angioplasty and continued for 6 months.

METHODS AND RESULTS

Before coronary angioplasty, 530 patients were randomly assigned to aspirin plus coumarins and 528 patients to aspirin alone. At the start of the angioplasty, the mean international normalized ratio was 2.7+/-1.1; during follow-up, it was 3.0+/-1.1. At 30 days, the composite end point of death, myocardial infarction, target-lesion revascularization, and stroke was observed in 18 patients (3.4%) treated with aspirin plus coumarin compared with 34 patients (6.4%) treated with aspirin alone (relative risk, 0.53; 95% CI, 0.30 to 0.92). At 1 year, these figures were 14.3% and 20.3%, respectively (relative risk, 0.71; 95% CI, 0.54 to 0.93). The incidence of major bleeding and false aneurysm during hospitalization was 3.2% and 1.0%, respectively (relative risk, 3.39; 95% CI, 1.26 to 9.11). The benefit of coumarins was observed in both stented and nonstented patients.

CONCLUSIONS

Coumarins in addition to aspirin started before PTCA and continued for 6 months was more effective than aspirin alone in the prevention of acute and late complications after coronary angioplasty. This benefit was accompanied by a small but significant increase in bleeding complications.

Influence of patient age on acute and late clinical outcomes following Palmaz-Schatz coronary stent implantation

Procedural success may be lower and complication rates higher after balloon angioplasty in older patients. Elective stent implantation improves procedural outcome in younger patients; however, few series have specifically analyzed the octogenarian population. Therefore, we studied 2,534 consecutive patients (3,965 native coronary artery stenoses) who were treated electively with Palmaz-Schatz stents and divided them into 3 groups: (1) < or = 70 years old (n = 1,805), (2) 71 to 80 years old (elderly, n = 607), and (3) > 80 years old (octogenarian, n = 122). Major in-hospital complications (death, myocardial infarction, and urgent bypass surgery) were significantly higher in the octogenarians than in the elderly and patients < or = 70 years of age (4.5% vs 2.0% and 1.5%; p = 0.001). At 1-year follow-up, cardiac events (death, nonfatal myocardial infarction, and need for any revascularization) did not differ among groups; however, there was a stepwise increase in late death in octogenarians (5%) compared with elderly patients (2%) and patients aged < or = 70 years (1%) (p = 0.001). Target lesion revascularization was similar among the groups (11% in octogenarian vs 14% in elderly and 15% in patients < or = 70 years, p = 0.791). By multivariate logistic regression analysis, age was an independent predictor of late mortality (odds ratio 1.05, p = 0.0001), but not a predictor of target lesion revascularization. Stent implantation in octogenarians is associated with (1) more acute complications, (2) a higher in-hospital mortality, (3) a higher late mortality, and (4) a target lesion revascularization similar to younger patients.

[Arterial myocardial revascularization in the 9th decade of life. Personal results and review of the literature]

The rate of the population being 80 years of age and even older, has an increasing tendency in the Federal Republic of Germany. In 1996, a total of 87,372 patients received surgery supported by the heart-lung-machine, 2,383 patients out of these (2.7%) were 80 years of age and older. In view of the limited life expectance, the arterial revascularization in this age category is faced with controverse discussions. We analysed our patients in relation to this aspect. Between January 1, 1995 and June 30, 1997, 4,338 patients underwent surgery supported by the heart-lung-machine. Hundred and fifty-five out of these (3.6%) were in the 9th decade of life. Seventy-seven patients out of the 155 (49.7%, 34 women, 43 men, 80 to 88 years old, mean: 82 years of age) underwent an isolated myocardial revascularization. We performed 55 (71%) elective, 16 (21%) urgent and 6 (8%) emergency surgeries. Twelve patients (15.6%) solely received venous bypasses (Group I), 65 (84.4%) additionally also received unilateral bypasses of the internal mammaria artery (IMA) (Group II). Three patients died at our facility (3.9%), 3 further patients died during the follow-up treatment in outlying hospitals, the in-patient mortality rate in Group I therefore presented a rate of 8.3%, in Group II 7.7% and in total, a rate of 7.8%. In 1996, the in-patient mortality rate could be reduced to 3.6%. The follow-up observation time ranged between 7 and 138 weeks (median 44 weeks). The survival rate for patients with an IMA-bypass after 1 year was 86.3%, after 2 years 77%, and for the entire collective 85.3% and 75%. Whereas 96% of the patients could pre-operatively be related to Class III or IV of the NYHA-classification, 55 of the 63 survivors (87%) belonged to Class I (6%) or II (81%). Two Group I patients (22.2%), 3 Group II patients (5.6%) and 7.9% of the total collective complained about repeated angina symptoms. The myocardial revascularization with the internal mammaria artery performed on patients in the 9th decade of life, achieves an acceptable morbidity and mortality compared to solely venous coronary bypasses. The more prolonged follow-up observation period will clarify, whether the arterial myocardial revascularization also proves to be the superior method in this age category.

Coronary artery stenting in the elderly: short-term outcome and long-term angiographic and clinical follow-up

OBJECTIVES

This study sought to compare the short- and long-term outcomes of elderly patients undergoing coronary artery stenting with those of younger patients and to determine the long-term clinical outcome and survival of elderly patients post stent implantation.

BACKGROUND

Elderly patients undergoing coronary revascularization are considered a high-risk group. Few data exist that relate the results of stenting in treating coronary artery disease in the elderly population.

METHODS

All elderly patients >75 years of age who underwent coronary artery stenting between March 1993 and July 1997 (n=137) at our center were compared to the patients <75 who underwent coronary artery stenting during the same time period (n=2,551). Long-term clinical follow-up and survival were determined for the elderly group.

RESULTS

Elderly patients presented with lower ejection fractions (54% vs. 58%, p=0.0001), more unstable angina (47% vs. 28%, p=0.0001), and more multivessel disease (78% vs. 62%, p= 0.0001) than younger patients. These older patients had higher rates of procedure related complications including procedural myocardial infarction (MI) (2.9% vs. 1.7%, p=0.2), emergency CABG (3.7% vs. 1.4%, p=0.04), and death (2.2% vs. 0.12%, p=0.0001). Angiographic follow-up, obtained in both groups, demonstrated significantly higher restenosis rates in the elderly versus younger patients (47% vs. 28%, p=0.0007). Longer term clinical follow-up, which was obtained only in the elderly group, showed that at a mean follow-up period of 12 months post coronary stenting, elderly survival free from death, MI, revascularization and angina was 54% and that their overall survival was 91%. Subanalysis of the elderly patients who died showed much higher incidence of combined unstable angina (80%), prior MI (60%), lower ejection fraction (46%), multivessel disease (100%) and complex lesions (100%) than the overall group.

CONCLUSIONS

Elderly patients who undergo coronary artery stenting have significantly higher rates of procedural complications and worse six month outcomes than younger patients, especially those who present with combined unstable angina, history of MI, EF < 50%, multivessel disease and complex lesions. Overall survival in the elderly population at 12 months postcoronary artery stenting was 91% and event-free survival was 54%.

One-month results of coronary stenting in patients > or = 75 years of age

Coronary artery bypass operations are associated with increased morbidity and mortality in the elderly. Similarly, it has been shown that coronary angioplasty is associated with a higher risk of complications in the elderly than in younger patients. The purpose of this study was to evaluate the 1-month outcome of elderly patients (>75 years old) who were included in the Stenting without Coumadin French Registry. From December 1992 to March 1995, 2,900 patients (mean age 61+/-11 years) were included in this registry. All patients were treated with ticlopidine (250 to 500 mg/day) for 1 month from the day of percutaneous transluminal angioplasty, aspirin (100 to 250 mg/day) for >6 months, and low-molecular-weight heparin (antiXa 0.5 to 1 IU/ml) for 1 month in phase II, 15 days in phase III, and 7 days in phase IV. No heparin was given in phase V. The study group included 233 patients (8.0%) > 75 years old (mean age 79+/-4), 44 (18%) of whom were women. All patients underwent dilatation of a native coronary vessel. One hundred seventeen had unstable angina (50.2%), 20 had postmyocardial infarction ischemia (8.6%), and 6 had acute myocardial infarction (2.6%). Indications for stenting were de novo lesion in 63 patients (27.0%), restenosis in 38 (16.3%), suboptimal result in 48 (20.6%), nonocclusive dissection in 56 (24.0%), and occlusive dissection in 28 (12.0%), respectively. Stented coronary arteries were the left anterior descending in 109 (46.8%), the right in 80 (34.3%), the left circumflex in 40 (17.2%), and the left main in 4 (1.7%). Palmaz-Schatz stents were used in 228 patients (82.0%), AVE microstents in 38 (13.7%), and other stents in 12 (4.3%). More than 1 stent was used in 48 patients (17.3%). The mean diameter of the balloon used for stenting was 3.31+/-0.38 mm and maximal inflation pressure was 12.2+/-2.9 atm. At one-month follow-up, vascular complications occurred in 5 patients, requiring surgery in 2 (1.3%), acute closure occurred in 1 (0.4%), subacute closure in 3 (1.3%), emergency or planned coronary artery bypass graft surgery in none, acute myocardial infarction in 4 (1.7%), stroke in 1 (0.4%), and death in 8 (3.4%). The composite end point of a major cardiac event was observed in 13 cases (5.6%). Coronary stenting using ticlopidine and aspirin appears to be a particularly safe approach in this high-risk subset.

Comparison of six-month outcome of coronary artery stenting in patients <65, 65-75, and >75 years of age

We studied 1,238 patients receiving 1,880 coronary stents. In-hospital outcomes were divided by age into <65 years (n = 747, group 1), 65 to 75 years (n = 326, group 2), and >75 years (n = 165, group 3). Procedural success was 97.2%, 95.1%, and 98.8% in groups 1, 2, and 3, respectively (p = NS). There was 1 death (group 1). Myocardial infarction occurred in 1.2%, 2.8%, and 1.8%, bypass surgery occurred in 0.9%, 1.8%, and 1.2%, and repeat balloon angioplasty in 0.3%, 0.6%, and 0% of patients in groups 1, 2, and 3, respectively (p = NS for all comparisons). Vascular complications occurred in 2.8%, 4.9%, and 6.1% in groups 1, 2, and 3, respectively (p <0.05). Six-month follow-up of patients was divided by age: <65 years (n = 564, group 1); 65 to 75 years (n = 221, group 2); and >75 years (n = 122, group 3). Event-free survival was 94.5%, 90.5%, and 89.3% for groups 1, 2, and 3, respectively (p = NS). Death occurred in 0.4%, 0.5%, and 1.6%; myocardial infarction occurred in 1.2%, 2.3%, and 1.6%, and target vessel revascularization in 4.3%, 8.6%, and 7.4% for groups 1, 2, and 3, respectively (p = NS for all comparisons). Thus, coronary stenting produced favorable in-hospital and 6-month outcomes in all 3 age groups. Age itself should not preclude patients from undergoing coronary stenting.

Long-term results after successful percutaneous transluminal coronary angioplasty in patients over 75 years of age

A prospective study comparing the long-term results of balloon angioplasty in patients over 75 years of age with those in a younger patient group is not available. A total of 192 consecutive patients aged > or = 75 years (group I) who underwent a balloon angioplasty were matched with 192 control patients aged 40 to 65 years (group II). The groups were matched for gender, angina pectoris class, left ventricular function, 1-, 2-, and 3-vessel coronary artery disease, and previous myocardial infarction. The mean follow-up was 40.4 months (range 0 to 110). Actuarial analysis (freedom from events) after 5 years yielded the following results for group I versus group II: free from death remained 77.1% versus 97.9% (p = 0.0001), from cardiac death 92.4% versus 97.9% (p = 0.049), and from angina pectoris 54.6% versus 75.1% (p = 0.03). The differences were not significant for those remaining free from myocardial infarction, repeat balloon angioplasty, or coronary artery bypass grafting. When elderly patients with complete revascularization (n = 127) were compared with a matched control group of 127 patients aged 40 to 65 years who underwent complete revascularization, there was only a significant difference in noncardiac death rates. We conclude that patients > 75 years of age have a significant higher cardiac and noncardiac death rate and a higher incidence of angina pectoris after successful balloon angioplasty. However, the incidence of reintervention and myocardial infarction is lower in the elderly. If complete revascularization is achieved in the elderly, then freedom from cardiac death and recurrence of angina pectoris would be comparable to that in younger patients.