Primary percutaneous coronary interventions in nonagenarians

Primary PCI in a nonagenarian: an uncommon predicament

Myocardial infarction in a nonagenarian is a morbid cardiac illness that can lead to significant mortality unless properly dealt with management aspects. Many comorbid or family-related issues might be part of holdbacks in management of such a group of patients. Hence, myocardial infarction in a nonagenarian where intervention is better treatment option forms an uncommon combination and has many preprocedural, periprocedural and postprocedural difficulties related to multiple issues. Here, we present a case of nonagenarian who presented with extensive anterior wall MI and was successfully dealt with primary percutaneous coronary intervention despite periprocedural and intraprocedural difficulties.

[Complications of coronary invasive procedures in nonagenarians: A case-control study]

INTRODUCTION

Coronary heart disease is the leading cause of morbidity and mortality in nonagenarians, whose numbers have doubled in twenty years. In the absence of recommendations, the place of coronary invasive strategy in this population remains a therapeutic challenge and its interest as well as its risks are poorly established. The aim of our study was to evaluate the safety of coronary invasive practice in the nonagenarian population for all indications.

POPULATION AND METHODS

This was a monocentric case-control study conducted from January 1, 2010 to May 30, 2019. The patients included were all nonagenarians who had undergone coronary angiography at the centre hospitalier de Troyes during this period. For each patient included, two controls matched on sex, date of procedure and procedure were drawn at random. The main judgment criterion was the occurrence of immediate per- or post-procedure complications during the stay in which the procedure was performed. The main secondary outcome measures were average length of stay, occurrence of intercurrent events during the stay (nosocomial infections, confusional syndrome), and loss of autonomy.

RESULTS

In all, 59 nonagenarians and 118 controls were included in our study. We identified 30.5% major complications in the nonagenarians versus 10.2% in the controls (P=0.001; OR=0.26 [0.1-0.6]), with a significant difference in the occurrence of cardiogenic shock (P=0.04), heart failure (P=0.02) and ventricular rhythm disorders (P=0.04). Post-procedure acute renal failure was greater in the nonagenarians (P=0.02; OR=0.20 [0.05-1.57]). The mean length of stay was on average twice as long in the nonagenarians.

CONCLUSION

Nonagenarian patients are subject to more complications when undergoing coronary invasive procedures compared to patients under 75.

Clinical outcomes in nonagenarians undergoing a percutaneous coronary intervention: data from the ORPKI Polish National Registry 2014-2016

BACKGROUND

Despite an increase in the proportion of nonagenarians in demographic structure, there is still a paucity of data on the utilization and outcome of percutaneous coronary interventions (PCIs) in this population. Also, very old patients are under-represented in randomized clinical trials and their treatment is still an emerging challenge. Thus, we sought to compare patient profiles and periprocedural outcomes of PCI in nonagenarians and patients younger than 90 years.

PATIENTS AND METHODS

Data were based on the Polish National Registry of PCI (ORPKI). A total of 651 080 consecutive patients with stable angina (SA) (n=260 920) or acute coronary syndrome (ACS) (n=390 160) undergoing PCI with at least one stent implanted were included. Patients were stratified according to age (<90 and ≥90 years).

RESULTS

Of all included patients, 4413 (0.7%) were older than or equal to 90 years. A similar rate of periprocedural complications was observed in both groups. However, cardiac arrest during both angiography and PCI occurred more often in nonagenarians (0.21 vs. 0.83%; 0.42 vs. 1.07%, respectively, for both P=0.001). Similarly, periprocedural mortality was higher in patients older than or equal to 90 years (0.27 vs. 1.88%; P=0.001). There were no differences in periprocedural outcomes between groups in the SA setting. However, a higher rate of periprocedural cardiac arrest [1971 (0.51%) vs. 43 (1.15%); P=0.001] and mortality [1622 (0.42%) vs. 83 (2.2%); P=0.001] were observed in nonagenarians compared with younger counterparts admitted with ACS.

CONCLUSION

Nonagenarians undergoing PCI because of SA may have similar outcomes as patients younger than 90 years. In ACS presentation, they may have worse outcomes than younger counterparts.

Primary Coronary Intervention in Octogenarians and Nonagenarians With ST-Segment Elevation Myocardial Infarction: A Canadian Single-Center Perspective

The proportion of individuals >80 years of age constitute an increasing proportion of patients who present with ST-segment elevation myocardial infarction (STEMI). The objective of this study is to evaluate in-hospital outcomes and 1-year survival of very elderly patients who present with an STEMI and undergo primary percutaneous coronary intervention (pPCI). Between 2009 and 2015, individuals >80 years of age (very elderly patients) with an STEMI presenting at a single tertiary Canadian care center were included in the study. A random sample of 100 individuals aged 65 to 69 years over the same time period were selected as a control group. A total of 284 patients were included in the study population including 100 controls, 164 octogenarians, and 20 nonagenarians. Of total, 1661 pPCIs occurred during this study period with the very elderly population (>80 years) comprising 11.1% of the total pPCIs. Compared with controls, individuals aged >80 are more likely to have a delay in treatment with increased rates of bleeding, acute kidney injury, rehospitalization, and a trend toward longer hospital stays following pPCI for STEMI. Although in-hospital and 1-year mortality were similar between both cohorts >80 years of age with STEMI, their overall survival was reduced compared with controls.

Temporal trends and in-hospital outcomes of primary percutaneous coronary intervention in nonagenarians with ST-segment elevation myocardial infarction

BACKGROUND/AIMS

Data regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) in nonagenarians are very limited. The aim of the present study was to evaluate the temporal trends and in-hospital outcomes of primary PCI in nonagenarian STEMI patients.

METHODS

We retrospectively reviewed data from the Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to January 2008, and from the Korea Working Group on Myocardial Infarction (KorMI) from February 2008 to May 2010.

RESULTS

During this period, the proportion of nonagenarians among STEMI patients more than doubled (0.59% in KAMIR vs. 1.35% in KorMI), and the rate of use of primary PCI also increased (from 62.5% in KAMIR to 81.0% in KorMI). We identified 84 eligible study patients for which the overall in-hospital mortality rate was 21.4% (25.0% in KAMIR vs. 20.3% in KorMI, p = 0.919). Multivariate analysis identified two independent predictors of in-hospital mortality, namely a final Thrombolysis in Myocardial Infarction (TIMI) flow < 3 (odds ratio [OR], 13.7; 95% confidence interval [CI], 3.2 to 59.0; p < 0.001) and cardiogenic shock during hospitalization (OR, 6.7; 95% CI, 1.5 to 30.3; p = 0.013).

CONCLUSIONS

The number of nonagenarian STEMI patients who have undergone primary PCI has increased. Although a final TIMI flow < 3 and cardiogenic shock are independent predictors of in-hospital mortality, primary PCI can be performed with a high success rate and an acceptable in-hospital mortality rate.

Percutaneous coronary intervention in the elderly

Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.

[Use and limitations of invasive coronary strategy in nonagerians]

BACKGROUND

Nonagenarians are systematically excluded from studies of interventional cardiology. Few data exist on the usefulness, safety, and results of coronary angiography (CA) and percutaneous coronary intervention (PCI) in this population.

PURPOSE

To evaluate the benefits and hazards of CA and PCI in nonagenarians.

METHODS

Retrospective study conducted from the database (Cardioreport(®)) of the CH de Versailles, from January 2001 to December 2011.

RESULTS

From the 15,806 procedures performed in the center during the period, 107 (0.9%) were done in 97 patients aged ≥90years. Half of them underwent PCI. Median age was 92±2years (range: 90 to 100), 56% were women. Main indication was an acute coronary syndrome (77%, acute STEMI in 39%). The first group (n=58) had a single CA leading to strengthen medical treatment, and CABG in one case. The second group (n=49) had a CA followed by immediate (41) or delayed (8) PCI. The primary success rate of PCI was 90%. Radial route was used in 94% in the period 2009-2011 (51% overall). Failure of arterial access (4%) and difficulties of catheterization (13%) were rare. Severe complications occurred in 19%. They were local (11 hematomas, 6 severe, 4 transfusions, and 1 fatal acute ischemia of a lower limb), and general (1 stroke, 1 death by left main rupture during PCI). Twenty percent of the complications (11% of severe ones) were directly related to the procedure. Overall hospital mortality was 10%.

CONCLUSIONS

Angiography is feasible in nonagenarians by radial approach without failures and with a reduced rate of complications. PCI was indicated in about half of the cases. PCI may be proposed in nonagerians with a high success rate, and an acceptable risk of local and general complications.

Percutaneous coronary intervention in nonagenarians: pros and cons

Percutaneous coronary intervention is a mainstay in the management of symptomatic or high-risk coronary artery disease. The bulk of clinical evidence and experience underlying this fact relies, however, on relatively young patients. Indeed, few data of very limited quality are available which adequately define the risk-benefit and cost-benefit profile of coronary angioplasty and stenting in very old subjects, such as those of 90 years of age or older (i.e., nonagenarians). The aim of this review is to provide a concise, yet practical, synthesis of the available evidence on percutaneous coronary revascularization in the very elderly. The main arguments elaborated upon are to what extent we can extrapolate findings from studies including younger patients to nonagenarians, whether we should provide higher priority to prognosis or quality of life in such patients, and whether we can afford to allocate vast resources to care for such subjects in an era of financial constraints. Our review of 18 studies and 1082 patients suggest that percutaneous coronary intervention is feasible and associated with acceptable short- and long-term results in this population, which is nonetheless fraught with a high mortality risk irrespective of the revascularization procedure. Accordingly, the pros and cons of percutaneous coronary intervention should be carefully weighed when considering this treatment in nonagenarians.

Cardiac catheterisation in nonagenarians: Single center experience

OBJECTIVE

To explore the treatment, procedure related risks, and outcomes of patients older than 90 years of age undergoing cardiac catheterization.

METHODS

We retrospectively studied 32 patients ≥ 90 years (93.0 ± 1.2 years) who underwent cardiac catheterisation in a tertiary specialist hospital (0.2% of 14,892 procedures during three years). The results were compared to a patient cohort younger than 90 years of age.

RESULTS

Baseline characteristics revealed a higher prevalence of diabetes (P < 0.001), chronic obstructive pulmonary disease (P < 0.04), previous myocardial infarction (P < 0.02), and complex coronary anatomy (SYNTAX score 33 vs. 19) in nonagenarians. Patients < 90 years of age showed more hyperlipidemia (P < 0.01) and previous percutaneous coronary interventions (P < 0.015). Nonagenarians underwent coronary angiography more often for acute coronary syndrome (ACS) (P < 0.003), were presented more often in cardiogenic shock (P < 0.003), and were transferred faster to coronary angiography in cases of ACS (P < 0.0001). The observed in-hospital mortality rate (13% study group vs. 1% control group; P < 0.003) in nonagenarians was lower than the calculated rate of thrombolysis in myocardial infarction (TIMI) and global registry of acute cardiac events (GRACE) mortality and strongly influenced by the severity of clinical presentation and the presence of co-morbidities.

CONCLUSION

Despite the common scepticism that cardiac catheterisation exposes patients ≥ 90 years to an unwarranted risk, our data demonstrate an acceptable incidence of complications and mortality in this group of patients.

Outcome of contemporary percutaneous coronary intervention in the elderly and the very elderly: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium

BACKGROUND

There is a paucity of data on the outcome of contemporary percutaneous coronary intervention (PCI) in the elderly. Accordingly, we assessed the impact of age on outcome of a large cohort of patients undergoing PCI in a regional collaborative registry.

HYPOTHESIS

Increasing age is associated with a higher incidence of procedural-related complications.

METHODS

We evaluated the outcome of 152,373 patients who underwent PCI from 2003 to 2008 in the 31 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. The procedural outcomes of the cohort were compared by dividing patients into < 70 years of age, 70 to 79 years, 80 to 84 years, 85 to 89 years, and ≥ 90 years.

RESULTS

Of the cohort, 64.64% were <70 years of age, 23.83% were 70 to 79 years, 7.85% were 80 to 84 years, 3.09% were 85 to 89 years, and 0.58% were 90 years or older. Increasing age was associated with an increase in all-cause in-hospital mortality, contrast-induced nephropathy, transfusion, stroke/transient ischemic attack, and vascular complications. The overall in-hospital mortality rate was 1.09% and increased from 0.67% in those younger than 70 years up to 5.44% in those 90 years old or greater. The mortality rate in patients over 80 years approached 12% to 15% for those with ST-segment myocardial infarction and 39% in cardiogenic shock patients.

CONCLUSIONS

The proportion of elderly patients referred for PCI is increasing. Procedural complications increase with age, and patients presenting with unstable symptoms are at the highest risk.

[Update on geriatric cardiology]

This article contains a review of the main developments in the field of geriatric cardiology reported during 2010. The focus is on research into the specific characteristics of elderly patients with heart failure, ischemic heart disease, valvular heart disease and arrhythmias.