Late outcome and quality of life following percutaneous transluminal coronary angioplasty in octogenarians

Effect of Age on Procedural Success, Complications, and Clinical Outcome From a Large Angioplasty Registry

BACKGROUND

Increasing age appears to be a risk factor for adverse outcome in patients undergoing percutaneous coronary intervention (PCI). The goal of this study was to compare procedural success, complications, and 12 months major adverse cardiac events (MACE) based on age using a large angioplasty registry.

METHODS

This registry included 10,412 patients with at least 12-month follow-up from April 1993 to April 2011. Patients were divided into 3 age groups: group 1 age < 60 (n = 6195), group 2 age 60-75 (n = 3724) and group 3 elderly age ≥ 75 (n = 493).

RESULTS

Procedural success rate was not significantly different across the 3 age groups. (96.9% in group 1, 97.1% in group 2, and 96.1% in elderly group, P = 0.759). Procedural complications occurred in 179 (2.9%) of group 1, 98 (2.6%) of group 2 and 15 (3.0%) of elderly group (P = 0.678). In-hospital complications increased with increasing age (311 [5.0%] in group 1, 235 [6.3%] in group 2, and 46 [9.3%] in elderly group; P < 0.001). Twelve-month MACE also increased with increasing age (235 [4.1%] in group 1, 169 [4.9%] in group 2 and 26 [5.7%] in elderly group; P = 0.021). Multivariate analysis showed that age was not a predictor for unsuccessful PCI, procedural complications, or 12-month MACE. However, increasing age was independent predictors of in-hospital complications and death.

CONCLUSION

Despite increased in-hospital complications with increasing age, procedural success, and complications were not higher in elderly. Our data suggest that PCI should not be denied in elderly if indicated with procedural safety similar to other age groups.

Sustained 3-Year Benefits in Quality of Life After Percutaneous Coronary Interventions in the Elderly: A Prospective Cohort Study

BACKGROUND

Impact of percutaneous coronary interventions (PCI) on health-related quality of life (HRQOL) is important but under-reported in elderly patients.

OBJECTIVES

To evaluate long-term health status in elderly patients who underwent PCI.

METHODS

Consecutive patients who underwent PCI at a university-affiliated hospital from September 2009 to June 2012 were prospectively enrolled with HRQOL assessment at baseline (up to 2 weeks before PCI) and at 6-, 12-, and 36-month follow-up using the EuroQol five-dimensional questionnaire descriptive profile and visual analogue scale (VAS). Minimally important benefit (MIB) in HRQOL was defined as greater than half an SD improvement in the baseline VAS score.

RESULTS

Of 1957 patients, 49.9%, 29.1%, and 21.0% were aged younger than 65 years, 65 to 74 years, and 75 years and older, respectively. Mean VAS scores at baseline (50.1 ± 20.5 vs. 51.6 ± 20.5 vs. 52.6 ± 21.8; P = 0.09) and at 36 months (72.9 ± 14.0 vs. 72.8 ± 16.1 vs. 72.0 ± 14.8; P = 0.77) were similar between the three age groups, respectively. MIB at 36 months was observed in 65.7%, 61.9%, and 61.2% of patients in each age group, respectively. Proportion of patients aged 75 years and older reporting problems in pain/discomfort and self-care reduced from 91.2% and 24.8% at baseline to 41.4% and 10.1% at 36 months, respectively (both P < 0.01). Independent predictors of MIB in HRQOL at 36 months in patients 75 years and older included poor baseline HRQOL, MIB at 6 months, and presentation with myocardial infarction (all P < 0.01).

CONCLUSIONS

Elderly patients experienced sustained long-term improvement in quality of life comparable with younger patients after PCI. Our findings suggest that age per se should not deter against revascularization because of sustained benefit in HRQOL.

Health-related quality of life in older patients with acute coronary syndrome randomised to an invasive or conservative strategy. The After Eighty randomised controlled trial

Objective

in the After Eighty study (ClinicalTrials.gov.number, NCT01255540), patients aged 80 years or more, with non-ST-elevation myocardial infarction (NSTEMI), and unstable angina pectoris (UAP), were randomised to either an invasive or conservative management approach. We sought to compare the effects of these management strategies on health related quality of life (HRQOL) after 1 year.

Methods

the After Eighty study was a prospective randomised controlled multicenter trial. In total, 457 patients aged 80 or over, with NSTEMI or UAP, were randomised to either an invasive strategy (n = 229, mean age: 84.7 years), involving early coronary angiography, with immediate evaluation for percutaneous coronary intervention, coronary artery bypass graft, optimal medical therapy, or to a conservative strategy (n = 228, mean age: 84.9 years). The Short Form 36 health survey (SF-36) was used to assess HRQOL at baseline, and at the 1-year follow-up.

Results

baseline SF-36 completion was achieved for 208 and 216 patients in the invasive and conservative groups, respectively. A total of 137 in the invasive group and 136 patients in the conservative group completed the SF-36 form at follow-up. When comparing the changes from follow-up to baseline (delta) no significant changes in quality-of-life scores were observed between the two strategies in any of the domains, expect for a small but statistically significant difference in bodily pain. This difference in only one of the SF-36 subscales may not necessarily be clinically significant.

Conclusion

from baseline to the 1 year follow-up, only minor differences in change of HRQOL as measured by SF-36 were seen by comparing an invasive and conservative strategy.

ClinicalTrials.gov identifier

NCT01255540.

Comparison of five-year outcome of octogenarians undergoing percutaneous coronary intervention with drug-eluting versus bare-metal stents (from the RESEARCH and T-SEARCH Registries)

Although octogenarians are increasingly referred for percutaneous coronary intervention (PCI), data are lacking on long-term safety and efficacy of drug-eluting stents in this high-risk subpopulation. The aim of this study was to evaluate 5-year clinical outcome of octogenarians who underwent PCI using sirolimus-eluting stents (SESs) or paclitaxel-eluting stents (PESs) compared to bare-metal stents (BMSs). From January 2000 to December 2005, 319 consecutive octogenarian patients who underwent PCI with BMSs (n = 93, January 2000 to April 2002), SESs (n = 52, April 2002 to February 2003), or PESs (n = 174, February 2003 to December 2005) were included prospectively. Primary study end points were all-cause mortality and major adverse cardiac events (MACEs), defined as all-cause death, any myocardial infarction, or any revascularization. Mean age of the study population was 83 ± 2 years and 51% of patients were men. Median follow-up duration was 5.4 years (range 3 to 9). Five-year mortality rates in the BMS, SES, and PES cohorts were similar (41%, 42%, and 41%, respectively). Cumulative 5-year MACE-free survival in the BMS, SES, and PES cohorts were 44%, 52%, and 48%, respectively. Compared to the BMS cohort, adjusted hazard ratios for MACEs in the SES and PES cohorts were 0.5 (95% confidence interval [CI] 0.3 to 0.9, p <0.05) and 0.5 (95% CI 0.2 to 1.4, p = 0.2), respectively. Overall, use of drug-eluting stents was associated with fewer MACEs (adjusted hazard ratio 0.5, 95% CI 0.3 to 0.9, p <0.05) and a trend toward less target vessel revascularization (adjusted hazard ratio 0.5, 95% CI 0.2 to 1.2, p = 0.1). In conclusion, PCI with drug-eluting stents in octogenarians was found to be safe and more effective compared to PCI with BMSs.

Percutaneous coronary interventions in nonagenarians: in-hospital mortality and outcome at one year follow-up

BACKGROUND

Limited information is available regarding outcome of very elderly patients referred for percutaneous coronary intervention (PCI).

PURPOSE

This study aimed to assess acute and intermediate term clinical outcomes among nonagenarians.

METHODS

The study included 32 consecutive nonagenarian patients undergoing PCI between January 2001 to August 2006. There were 6 (19%) patients admitted with acute ST-segment elevation myocardial infarction (STEMI), 10 (31%) patients with non-STEMI, and 16 (50%) patients with unstable angina pectoris. Receiver-operator characteristic curve (ROC) analysis was done to define the relationship between heart rate, blood pressure, left ventricle ejection fraction, serum creatinine level, and mortality.

RESULTS

Results: Immediate procedure success was achieved in 28 (88%) patients. Cumulative mortality at hospital discharge was 3(9%), at 6 months it was 6 (19%) and remained 6(19%) at 1 year follow-up.

CONCLUSION

Hypotension and low ejection fraction correlated with in-hospital mortality and worst clinical outcome. Procedural success does not appear to decline in nonagenarians.

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.

Benefits on coronary restenosis from elective paclitaxel-eluting stent implantation in patients aged 75 years and older

OBJECTIVE

Elderly patients are increasingly referred for revascularisation yet have been underrepresented in some large clinical trials. Although the advent of drug-eluting stents has dramatically reduced clinical events related to restenosis, older age remains one of the most important correlates of adverse outcome, even after an elective percutaneous coronary intervention (PCI). We sought to evaluate the impact of paclitaxel-eluting stents on coronary restenosis in elderly patients undergoing elective PCI.

METHODS

Patients undergoing successful elective PCI with stenting of de novo coronary artery lesions were identified and screened for participation in this study. All patients included in our analysis were divided into two cohort groups: patients aged <75 years (younger cohort) and patients aged >or=75 years (elderly cohort). We evaluated the six-month incidence of target lesion revascularisation (TLR) and major adverse cardiac events, which included TLR, death and myocardial infarction.

RESULTS

A total of 171 (58 aged >or=75 years) consecutive patients were enrolled in the study. At six months, TLR rate was similar in both groups [1.77 vs. 1.72%, odds ratio (OR) 0.97, 95% confidence interval (CI) 0.08-10.9, P = 0.98, in the younger and elderly group, respectively]. Even the rate of major adverse cardiac events was comparable between the two groups (7.96 vs. 8.62%, OR 1.09, 95% CI 0.34-3.41, P = 0.88, in the younger and elderly group, respectively). Also the angiographic restenosis rates were comparable between patients <75 or >or=75 years (4.42 vs. 3.46%, P = 0.76).

CONCLUSIONS

After elective paclitaxel-eluting stent implantation, there is no difference in coronary restenosis in younger and elderly patients, suggesting an age-independent efficacy.

Current issues in coronary artery stenting in the elderly

The aim of this review is to present current trends and outcomes among elderly patients undergoing coronary stenting for treatment of symptomatic coronary artery disease. Elderly patients are at higher risk for morbidity and mortality after coronary revascularization procedures. Acute and long-term outcomes relative to increased baseline risk factors and other competing mortality risks are reviewed for stenting and the alternatives of medical or surgical treatment. Improvement in quality of life is discussed as an outcome that some have regarded as more germane than simple survival in this population. Caution is urged for the often avoidable complications related to vascular injury, bleeding and contrast nephropathy, which are more common in the elderly after stenting and are independently associated with increased mortality. The authors also review the increasing relevance of coronary stent outcomes among the elderly in the context of the newer drug-eluting stents that have revolutionized percutaneous revascularization strategies.

Results of percutaneous coronary interventions in patients ≥90 years of age

BACKGROUND

There are few data about percutaneous coronary interventions (PCI) in nonagenarians (patients aged > or =90 years). This study aimed to assess acute and intermediate term clinical outcomes among nonagenarian patients undergoing PCI.

METHODS

The study included 65 consecutive patients, age > or =90 years undergoing PCI between January 2001 and August 2006. Fourteen patients were admitted with acute ST elevation acute myocardial infarction (STEAMI), one had cardiogenic shock, 39 patients sustained non-STEAMI, and 12 patients were with severe stable angina pectoris. Procedural data, in-hospital, and six-month clinical outcomes were obtained and adjudicated for all patients.

RESULTS

Coronary angiography documented multivessel disease in 86% of patients with relatively complex lesions (type B or C) in 94% treated using stent deployment in 92% of patients. In 7% of cases IABP was needed. Immediate procedural success was achieved in 92% patients. Cumulative mortality at hospital discharge and by 30-days was 14% and increased to 18% at 6-months follow-up. Total major adverse cardiac events (MACE: death, AMI, TVR, stroke) was 17% at hospital discharge and increased to 21% by 6-months. Stroke was documented in one patient (1.5%) at hospital discharge. Cumulative mortality at 6 month was 0% in patients with stable angina and 23% in emergent PCI scenario (AMI or NSTEAMI or ACS). Univariate analysis revealed that emergent PCI, systolic blood pressure, left ventricular ejection fraction, diabetes mellitus, renal failure, TIMI flow at baseline, and procedural success, are all correlative with 6-months mortality.

CONCLUSION

We conclude that clinically stable nonagenarian patients with coronary artery disease undergoing PCI have excellent PCI related prognosis while clinically unstable patients have a worse outcome. Thus, careful attention to background medical history and clinical presentation should dictate the prognosis and/or management among nonagenarian patients.

Comparison of outcomes of percutaneous coronary interventions in patients of three age groups (<60, 60 to 80, and >80 years) (from the New York State Angioplasty Registry)

Octogenarians have been under-represented in percutaneous coronary intervention (PCI) trials despite an increase in referrals for PCI. As the United States population ages, the number of high-risk PCIs in the elderly will continue to increase. This study investigated the effect of age on short-term prognosis after PCI in 3 age groups. Using the 2000/2001 New York State Angioplasty Registry, we compared in-hospital mortality and major adverse cardiac events (MACEs; death, stroke, or coronary artery bypass grafting) in emergency and elective PCI cohorts across 3 age categories of patients: 10,964 patients who underwent emergency PCI (<60 years of age, n = 5,354; 60 to 80 years of age, n = 4,939; >80 years of age, n = 671) and 71,176 patients who underwent elective PCI (<60 years of age, n = 24,525; 60 to 80 years of age, n = 40,869; >80 years of age, n = 5,782). Patients were considered to have undergone an emergency PCI if they had an acute myocardial infarction within 24 hours, had thrombolytic therapy within 7 days, or presented with hemodynamic instability or shock. Elderly patients had more co-morbidities, including more extensive coronary atherosclerosis, hypertension, peripheral vascular disease, and renal insufficiency, and presented more frequently with hemodynamic instability or shock. In the emergency PCI group, in-hospital mortality (1.0% vs 4.1% vs 11.5%, p <0.05) and MACEs (1.6% vs 5.2% vs 13.1%, p <0.05) increased incrementally by age group. In the elective PCI group, rates of in-hospital complications were considerably lower, with an incremental increase in mortality (0.1% vs 0.4% vs 1.1%, p <0.05) and MACEs (0.4% vs 0.7% vs 1.6%, p <0.05). Age was strongly predictive of in-hospital mortality for emergency and elective PCI by multivariate analysis. In conclusion, elective PCI in the elderly has favorable outcome and acceptable short-term mortality in the stent era. Elderly patients, in particular octogenarians undergoing emergency PCI, have a substantially higher risk of in-hospital death.

[Unstable angina in the elderly]

Unstable angina and acute coronary syndromes without persistent ST-segment elevation are frequent and their prognosis is poor in the elderly. Indeed, age is the most powerful predictor of in-hospital mortality in this setting. The clinical benefit of interventional strategies, as demonstrated by FRISC II and TACTICS TIMI 18 studies, seems to be most important in this age subset. PURSUIT trial demonstrates that the efficacy of eptifibatide, a IIb/IIIa platelet receptor inhibitor, increases in elderly patients who simultaneously undergo revascularization interventions. Individual application of such treatment strategies may be difficult. Potential triggering factors of unstable angina and comorbidities have to be taken into account, and the overall management should be highly individualized in elderly patients. The aim remains to achieve appropriate myocardial revascularization, as often as possible by focusing coronary angioplasty on the culprit vessel. Coronary surgery generally should be reserved for coronary lesions which are not suitable for percutaneous revascularization. Clinical improvement is maximal in patients with severe initial presentation.

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.

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.

Predictors of patient-reported physical and mental health 6 months after percutaneous coronary revascularization

BACKGROUND

There is interest in measuring and comparing outcomes of percutaneous transluminal coronary angioplasty (PTCA) other than death, but there are no accepted methods for adjusting these outcomes for preprocedure differences in populations. We sought to identify independent predictors of functional outcome after PTCA.

METHODS AND RESULTS

We developed multivariate risk adjustment models for the 6-month postprocedure physical and mental health summary scores of the MOS SF-36. Complete data were available on 1182 patients undergoing PTCA at 12 institutions. The mean physical component score (PCS) of the SF-36 rose from 36.6 before PTCA to 43. 4 at 6 months after PTCA (P <.0001). Independent predictors of follow-up PCS were baseline PCS, a composite index of comorbidities, prior coronary bypass surgery, baseline MOS SF-36 mental component score (MCS), age, and recent thrombolysis. The model had an adjusted R(2) value of 0.357. The mean MCS rose from 48.5 before PTCA to 50.5 at 6 months after PTCA (P <.0001). Independent predictors of postprocedure mental health were baseline MCS, age, and heart failure. The predictive model for MCS had an adjusted R(2) value of 0.235.

CONCLUSIONS

Preprocedure patient-reported functional status and select clinical variables are significantly associated with physical functioning and mental health 6 months after PTCA. The predictive power of these models, however, is probably insufficient to allow their use for comparisons among institutions or providers.

[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.

The challenge of health care delivery to the elderly patient with cardiovascular disease. Demographic, epidemiologic, fiscal, and health policy implications

Old age as our society is experiencing it is a new phenomenon. Never before in history have societies of developed countries enjoyed such longevity of life. In the next several decades the United States will face an unparalleled increase in the absolute number of elderly persons in our population. How will health care professionals, policy-makers, and society in general face the mammoth task of providing quality cardiovascular care for the elderly in an environment of limited financial resources? This article discusses the demographic, fiscal, and health policy implications of our aging society with particular emphasis on existing and anticipated impediments to the delivery of cardiovascular care to this rapidly expanding segment of our population.

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%.

Coronary artery disease in the geriatric population

The elderly represent an increasingly important and challenging subset of the population of patients with ischemic heart disease. They are more likely to have comorbid conditions, atypical presentations, and unfavorable outcomes than their younger counterparts. Some of these findings are undoubtedly related to the structural and functional changes in the cardiovascular system associated with aging. The available data suggest that standard pharmacologic, thrombolytic, and definitive revascularization techniques have important roles in the therapy of geriatric patients but have been underused.

Quality of life in octogenarians after open heart surgery

OBJECTIVES

To determine the quality of life in octogenarians after open heart surgery.

BACKGROUND

Despite an increasing number of cardiac operations on octogenarians, the outcome as measured by functional status, independence of living, and psychological parameters of quality of life remain unproved.

METHODS

Two groups of octogenarians (group 1, undergoing operation in 1986; group 2 in 1991) were reviewed retrospectively to determine operative mortality and functional results.

RESULTS

Group 1 (n = 15, mean age of 83.2 years) and group 2 (n = 53, mean age 83.0 years) were studied. Operations included isolated coronary artery bypass grafting (group 1, 10; group 2, 29) and valve replacements +/- coronary artery bypass grafting +/- other procedures (group 1: 5; group 2, 24). Group 1 had 9% hospital mortality and 53% actuarial survival after a mean follow-up of 6.3 years. Group 2 had 17% hospital mortality and 72% actuarial survival after a mean follow-up of 1.5 years. At follow-up, significant improvements were observed in New York Heart Association (NYHA) angina class, congestive cardiac failure class, number of cardiovascular symptoms, and indices for satisfaction with overall life and general affect in both groups. Further, group 2 also showed significant improvements in independence of living, ease of life, and Karnofsky dependency category, but these improvements were less evident in group 1 after a longer period of follow-up. At follow-up, 75% of group 1 and 84% of group 2 octogenarians would definitely have made the same decision to undergo open heart surgery in retrospect.

CONCLUSION

This study demonstrates improved quality of life after open heart surgery in octogenarians.

Morbidity and mortality rates in elderly patients undergoing percutaneous coronary transluminal angioplasty

Although successful dilatation of a target lesion by means of percutaneous transluminal coronary angioplasty (PTCA) can be attained as frequently in elderly as in younger patients, elderly patients have a higher risk of complications. Furthermore, cohorts of patients older than 75 years and undergoing PTCA include more women and more cases of unstable angina, factors that increase the risk of complications. Included in this analysis of 3199 PTCAs performed between January 1991 and September 1992 were 474 (14.8%) patients who were > or = 75 years old. Age was an independent risk factor for death, acute myocardial infarction, need for transfusion, and need for arterial repair after PTCA. The frequency of successful dilatation of individual lesions, emergency coronary bypass surgery, or repeated PTCA of the same lesion was not related to age. In previous studies no association has been demonstrated between age and increased risk of in-hospital reclosure. The presence of more severe coronary disease and of the greater frequency of coexisting morbid conditions makes elderly patients less able to tolerate unsuccessful or complicated PTCA.