Outcome and quality of life one year after percutaneous coronary interventions in octogenarians

Factors associated with health-related quality of life in patients undergoing percutaneous coronary intervention: Thai PCI registry

Background

Percutaneous coronary intervention (PCI) has been shown to improve health-related quality of life (HRQoL) in patients with coronary artery disease (CAD). The objectives of this study were to assess the changes in HRQoL and factors influencing these changes in CAD patients after undergoing PCI.

Methods

Data from a nationwide PCI registry across 39 hospitals in Thailand were collected in 2018-2019, including baseline characteristics, comorbid diseases, angiographic CAD severity, procedural details, and type of health insurance. HRQoL, as measured by utility scores, was determined in all patients using the Thai version of EQ-5D-5l at admission, discharge, and 6 and 12 months after discharge. The effects of time after PCI procedure and various factors on mean utility scores were assessed using a mixed-effect linear regression model.

Results

A total of 19,701 patients were included in the analysis; they had a mean age of 64.2 ± 11.7 years and were predominantly (69.1%) male. Following PCI, the mean utility scores increased from 66.6 ± 19.6 at admission to 81.9 ± 13.8 at discharge, and remained stable at 6 and 12 months (86.1 ± 12.3 and 88.0 ± 11.7, respectively). After adjusting for potential confounding variables, several factors were found to be independently associated with improved HRQoL, including angiographic success, male gender, overweight status, dyslipidemia, and radial access. Six other factors were associated with less improved HRQoLs, including cardiogenic shock/IABP support, old age, CKD, clinical presentation (STEMI and NSTEMI), prior cerebrovascular disease, and heart failure. There were no associations of CAD severity and procedural details with HRQoL. No differences were found related to type of health insurance, except that patients who were uninsured or self-pay tended to have less improvement in HRQoL.

Conclusion

HRQoL improved significantly after PCI in these subjects, as observed through 1 year of follow-up. Identifying the factors influencing these improvements may assist clinicians in tailoring patient interventions to optimise quality of life after PCI.

What matters most to patients following percutaneous coronary interventions? A new patient-reported outcome measure developed using Rasch analysis

INTRODUCTION

Measuring patient reported outcomes can improve the quality and effectiveness of healthcare interventions. The aim of this study was to identify the final set of items that can be included in a patient-reported outcome measure to assess recovery of patients following percutaneous coronary interventions.

METHODS

A consecutive sample of 200 patients registered in the Victorian Cardiac Outcomes Registry participated in a telephone survey 30 days following their percutaneous cardiac procedure. Rasch analysis was used to select the best set of items to form a concise and psychometrically sound patient-reported outcome measure. Key measurement properties assessed included overall fit to the Rasch measurement model, unidimensionality, response formats (thresholds), targeting, internal consistency and measurement invariance.

RESULTS

Five items were identified as being reliable and valid measures of patient-reported outcomes: pain or discomfort, shortness of breath, confidence in performing usual activities, feeling unhappy and having trouble sleeping. Data showed overall fit to a Rasch model of expected item functioning (χ2 16.99; p = 0.07) and all items demonstrated unidimensionality (t-test less than 0.05 threshold value). Internal consistency was acceptable (equivalent Cronbach's α 0.65) given there are only five items, but there was a ceiling effect (mean logit score -1.24) with compromised score precision for patients with better recovery.

CONCLUSIONS

We identified a succinct set of items that can be used in a patient-reported outcome measure following percutaneous coronary interventions. This patient-report outcome measure has good structural validity and acceptable internal consistency. While further psychometric evaluations are recommended, the items identified capture the patient's perspective of their recovery following a percutaneous coronary intervention.

Improved short and long term survival associated with percutaneous coronary intervention in the elderly patients with acute coronary syndrome

BACKGROUND

Percutaneous coronary intervention (PCI) are increasingly used in daily clinical practice in elderly patients with acute coronary syndrome (ACS) despite limited evidence. The purpose of this study was to assess the impact of PCI on short and long term survivals in a large cohort of elderly patients with ACS from a "real world".

METHODS

We enrolled 491 patients aged ≥70 years admitted to our institution with ACS from 2006 to 2012. Effect of PCI on short and long term survival was evaluated in both overall and a propensity score-matched cohort.

RESULTS

The mean age of the overall cohort is 83 ± 6 years. Among them, 285 were treated with PCI, whereas 206 were not. Patients treated with PCI were younger (82 ± 5 vs. 85 ± 6), more males (67% vs. 46%), with lower heart rate (77 ± 22 vs. 84 ± 21), higher eGFR (58 ± 20 vs. 47 ± 23), and less with heart failure (29% vs. 15%) (all p < 0.001). In both overall and propensity-matched population, improved survival was associated with PCI-treatment at 1 and 3 years (p < 0.001 for all comparisons). Furthermore, by using multivariate Cox proportional-hazards regression model following factors were identified as independent predictors of 3-year all-cause mortality: age (HR 1.08, 95% CI 1.00-1.16), heart rate (HR 1.02, 95% CI 1.01-1.03), eGFR (HR 3.07, 95% CI 1.63-5.77), malignancy (HR 2.03, 95% CI 1.27-4.57), prior CABG (HR 2.033, 95% CI 1.27-4.57), medication with statin (HR 0.40, 95% CI 0.19-0.86) in PCI group, whereas age (HR 1.08, 95% CI 1.03-1.13), heart rate (HR 1.01, 95% CI 1.01-1.02), hypertension (HR 1.87, 95% CI 1.01-3.49) and using of ACEI/ARB (HR 0.46, 95% CI 0.28-0.76) in non-PCI group.

CONCLUSIONS

In elderly ACS patients, PCI-treatment was associated with improved 1 and 3-year survival and PCI-treated patients had different prognostic profile compared to those without PCI treatment.

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 the Effects of Coronary Artery Bypass Grafting Versus Medical Therapy on Short and Long Term Outcomes in Octogenarian Patients With Multi-Vessel Coronary Artery Disease

Background:

Appropriate treatment methods lead to a reduced rate of mortality and morbidity, and an improved quality of life, in patients with multi-vessel coronary artery disease.

Objectives:

In this study, we compared short and long-term outcomes of coronary artery bypass grafting (CABG) versus medical therapy in patients 80 years of age and older with multi-vessel coronary artery disease (MVCAD).

Patients and Methods:

In this retrospective study, 50 octogenarian patients with MVCAD who underwent CABG were compared with 50 patients in the same condition who were treated with medical therapy during the same time. The primary objective was to compare mortality and morbidity rates, as well as other factors such as the occurrence of chest pain, deterioration of the NYHA functional class, and re-hospitalization, between the two groups. The comparison was made using medical records from the five years post-treatment.

Results:

After five years, the overall mortality rate included 11 patients (22%) in the CABG group versus 18 patients (36%) in the medical therapy group; this difference was not significant between the two groups (P = 0.186). Regarding short-term outcomes, in the CABG group, cardiogenic shock occurred in 9 patients (18%), renal failure in 13 patients (26%), pulmonary complications in 9 patients (18%) and neurologic complications in 3 patients (6%); in the medical therapy group, these same complications occurred, respectively, in 6 patients (12%), 7 patients (14%), 10 patients (20%) and 1 patient (2%). In addition to these factors, freedom from chest pain and improvement in the functional class among the CABG group was significantly higher than among the medical therapy group (P = <0.001).

Conclusions:

CABG may be the superior form of treatment for long-term outcomes in terms of the relief of chest pain, improvement of the functional class, reduced need for re-admission, and later death for octogenarians. However, short-term morbidity may be higher among the CABG group, but the mortality rate after 30 days is quite similar.

Factors influencing health-related quality of life after primary percutaneous coronary intervention for ST-elevation myocardial infarction

AIMS

This study compared health-related quality of life (HRQOL) between patients aged ≥ 70 and <70 years at 4 weeks and 6 months after primary percutaneous coronary intervention (PPCI) and examined predictors of HRQOL.

BACKGROUND

HRQOL is an important patient outcome following PPCI for ST elevation myocardial infarction (STEMI) including pre-hospital field triage.

METHODS

A comparative cohort design was conducted on STEMI patients undergoing PPCI. HRQOL was measured using the Medical Outcomes Short Form-12 (SF-12) and the Seattle Angina Questionnaire (SAQ) at 4 weeks and 6 months post-PPCI.

RESULTS

HRQOL improved significantly from 4 weeks to 6 months in all aspects measured except anginal frequency and mental health. Patients aged ≥ 70 years had poorer physical HRQOL (SF-12) and physical limitations (SAQ), but better mental HRQOL (SF-12), angina frequency and QOL (SAQ) at both time points. Age, length of hospital stay, gender, partnership status and number of stents deployed are independent predictors of HRQOL improvement over time.

CONCLUSION

People ≥ 70 years reported better cardiac-specific quality of life, primarily from angina relief and improved mental function, despite worse physical limitations. HRQOL assessment is an important gauge of health status after PPCI for STEMI.

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.

Systematic review of health-related quality of life in older people following percutaneous coronary intervention

People aged over 60 years represent an increasingly high proportion of the population undergoing percutaneous coronary intervention. While risks are greater for older people in terms of major adverse cardiovascular events and higher mortality for this treatment, it is unclear if the benefits of health-related quality of life outcomes may outweigh risks. A search of the PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica, and Cochrane databases was conducted for the period from January 1999 to June 2012 using key words "percutaneous coronary intervention"/"angioplasty," "older," "elderly," and "quality of life"/"health-related quality of life." Using a systematic review approach, data from 18 studies were extracted for description and synthesis. Findings revealed that everyone regardless of age reported better health-related quality of life, primarily from the relief of angina and improved physical and mental function. Age itself did not have an independent predictive effect when other factors such as comorbid conditions were taken into account. Assessment of older peoples' health status following percutaneous coronary intervention by nurses and other health professionals is therefore important for the provision of quality care.

Quality of life after percutaneous coronary intervention: part 1

Quality of life (QOL) is a complex concept comprised of biopsychosocial, spiritual and environmental dimensions. However, the majority of research addresses only its physical function perspectives. This two-part series examines the holistic perspective of QOL of patients after percutaneous coronary intervention (PCI). Part 1 explains the research process of a cross-sectional descriptive study and its limitations. Data were collected by a mailed WHOQOL-BREF questionnaire in Maltese from a systematic sample of patients who had undergone PCI; the response rate was 64% (n=228; males n=169, females n=59, age 40-89 years). Part 1 also considers limitations, such as its cross-sectional design and retrospective data collection. The hierarchy of human needs theory (Maslow, 1999) guided the study. Part 2 gives the findings on the holistic view of QOL. Having social and family support, as a characteristic of Maltese culture appeared to contribute towards a better QOL.

Outcome and quality of life one year after percutaneous coronary interventions in octogenarians

BACKGROUND

While percutaneous coronary intervention (PCI) is increasingly being performed in octogenarians, little is known about the quality of life (QOL) one year after PCI. We assessed the one-year outcome and QOL after PCI.

METHODS

Outcome and QOL at one year were assessed in patients of 80 years and older who underwent PCI at our institution. We used the RAND-36 Health Survey to assess health-related QOL at follow-up. The EuroSCORE was used for reference risk assessment.

RESULTS

Ninety-eight patients (mean age 82.7+/-2.9 years; 60% female) underwent PCI. Acute PCI was performed in 36% of the patients. Canadian Cardiovascular Society (CCS) angina class before the procedure was class III for 28% and class IV for 64%. Of the patients, 98% were in the highest-risk group (additive EuroSCORE 6+). The overall PCI success rate was 94%. Mortality at one year was 19% (38% acute vs. 12% elective PCI). At followup, general health was rated as fairly good and better then before PCI (CCS I and II: 77%). RAND-36 scores for the mental component were better than scores for the physical component. Physical functioning (41+/-28) and role limitations caused by physical health problems (32+/-37) had the worst scores. The mental component vitality had the lowest (55+/-20) and mental health the highest (70+/-21) score. Social functioning was in general good (67+/-26).

CONCLUSION

Octogenarians have a high mortality risk following PCI, especially in acute PCI. In survivors QOL is acceptable with a better mental than physical score. In general, PCI in octogenarians has a positive effect on health perception, with less symptoms of angina pectoris. (Neth Heart J 2008;16:117-22.).