Percutaneous coronary intervention outcomes in octogenarians during the stent era (National Cardiovascular Network)

A Newly Defined CHA2DS2-VA Score for Predicting Obstructive Coronary Artery Disease in Patients with Atrial Fibrillation-A Cross-Sectional Study of Older Persons Referred for Elective Coronary Angiography

Purpose: Atrial fibrillation (AF) can be a valuable indicator of non-obstructive coronary artery disease (CAD) among older patients indicated for elective coronary angiography (CAG). Appropriate stratification of AF patients is crucial for avoiding unnecessary complications. The objective of this study was to identify independent predictors that can allow diagnosing obstructive CAD in AF patients over 65 years who were indicated to undergo elective CAG. Patients and methods: This cross-sectional study included 452 (23.9%) AF patients over 65 years old who were directed to the Department of Invasive Cardiology at the Medical University of Bialystok for elective CAG during 2014−2016. The participants had CAD and were receiving optimal therapy (median age: 73 years, interquartile range: 69−77 years; 54.6% men). The prevalence and health correlates of obstructive CAD were determined, and a multivariate logistic regression model was generated with predictors (p < 0.1). Predictive performance was analyzed using a receiver-operating characteristic (ROC) curve analysis. Results: Stenosis (affecting ≥ 50% of the diameter of the left coronary artery stem or ≥70% of that of the other important epicardial vessels) was significant in 184 (40.7%) cases. Multivariate regression analysis revealed that only the male sex (odds ratio [OR]: 1.80, 95% confidence interval [CI]: 1.14−2.84, p = 0.01) and the newly created CHA2DS2-VA score (OR: 3.96, 95% CI: 2.96−5.31, p < 0.001) significantly increased the chance of obstructive CAD, while controlling for chronic kidney disease and anemia. The ROC curve analysis indicated that the CHA2DS2-VA scale may be a useful screening tool for the diagnosis of obstructive CAD (area under the ROC curve: 0.79, 95% CI: 0.75−0.84, p < 0.001), with ≥4 being the optimal cutoff value. Conclusions: Our study has proven that several older AF patients who are advised to undergo elective CAG have nonobstructive CAD. The CHA2DS2-VA score can contribute to improving the selection of patients for invasive diagnosis of CAD, but further investigation is required.

Differences of patients' perceptions for elective diagnostic coronary angiography and percutaneous coronary intervention in stable coronary artery disease between elderly and younger patients

Aims

There is limited evidence of the differences in expectations between elderly (≥80 years) and younger patients (<80 years) regarding treatment success of percutaneous coronary interventions (PCI). We conducted a survey in patients undergoing diagnostic coronary angiography (DA) and/or intervention (PCI) to identify differences in patient perceptions between elderly and younger patients.

Methods and results

This is an all-comers study of consecutive patients who underwent DA and/or PCI. Patients were asked to fill out a questionnaire prior to DA/PCI. This questionnaire consisted of ten questions with potential patient expectations based on an increasing scale of importance from 0 to 5 which were related to the procedure (eg, extend life, decrease symptoms etc.) and the value of "hard" cardiac endpoints like death, stroke, acute myocardial infarction and target lesion revascularization for the patient. Among 200 patients (mean age 76.6±9.3 years, 60.5% male, ejection fraction 63.7%±13.2%), 100 patients (50%) were ≥80 years. For these elderly patients the questions "to remain independent," "to maintain mobility, so that I can maintain my current life," and "to prevent myocardial infarction" were rated highest. Regarding "hard" cardiac endpoints "to avoid PCI in the future" was rated lowest in younger and in elderly patients. Significant differences were found between the age groups with the items "to avoid myocardial infarction," "avoid heart insufficiency," "to extend my life" and "to maintain mobility so that I can maintain my current life" (P<0.001).

Conclusions

In our survey we found significant differences in patient expectations between elderly and younger patients regarding the outcome of DA/PCI.

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.

Outcome of 1051 Octogenarian Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Observational Cohort From the London Heart Attack Group

BACKGROUND

ST-segment elevation myocardial infarction is increasingly common in octogenarians, and optimal management in this cohort is uncertain. This study aimed to describe the outcomes of octogenarians with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention.

METHODS AND RESULTS

We analyzed 10 249 consecutive patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention between 2005 and 2011 at 8 tertiary cardiac centers across London, United Kingdom. The primary end point was all-cause mortality at a median follow-up of 3 years. In total, 1051 patients (10.3%) were octogenarians, with an average age of 84.2 years, and the proportion increased over the study period (P=0.04). In-hospital mortality (7.7% vs 2.4%, P<0.0001) and long-term mortality (51.6% vs 12.8%, P<0.0001) were increased in octogenarians compared with patients aged <80 years, and age was an independent predictor of mortality in a fully adjusted model (hazard ratio 1.07, 95% CI 1.07-1.09, P<0.0001). Time-stratified analysis revealed an increasingly elderly and more complex cohort over time. Nonetheless, long-term mortality rates among octogenarians remained static over time, and this may be attributable to improved percutaneous coronary intervention techniques, including significantly higher rates of radial access and lower bleeding complications. Variables associated with bleeding complications were similar between octogenarian and younger cohorts.

CONCLUSIONS

In this large registry, octogenarians undergoing primary percutaneous coronary intervention had a higher rate of complications and mortality compared with a younger population. Over time, octogenarians undergoing primary percutaneous coronary intervention increased in number, age, and complexity. Nevertheless, in-hospital outcomes were reasonable, and long-term mortality rates were static.

Interventional treatment and outcome in elderly patients with stable coronary artery disease. Results from the German ALKK registry

BACKGROUND

The number of elderly and very elderly patients undergoing percutaneous coronary interventions (PCI) is increasing. We therefore analyzed data from the German ALKK registry (Arbeitsgemeinschaft Leitende Krankenhausärzte; Working Group of Hospital Cardiologists) to determine differences in procedural features, antithrombotic treatment, and in-hospital outcome in patients with coronary artery disease (CAD) according to age in a large series of patients.

METHODS AND RESULTS

The present analysis was based on the data of 35,534 consecutive patients undergoing elective PCI who were enrolled in the ALKK registry. Of these 27,145 (76.4 %) were younger than 75 years, 7,645 (21.5 %) were aged between 75 and 84 years, and 744 (2.1 %) patients were older than 85 years. Mean age was 68.5 years (60.9-74.5 years), and 25,784 patients (72.6 %) were male. Overall intraprocedural events were very low (1.1 %) and there was no significant difference between the three age groups [< 75 years (1.1 %); 75-< 85 years (1.2 %); ≥ 85 years (0.5 %) (p = not significant)]. Rates of in-hospital death, stroke and transient ischemic attack (TIA), as well as the combined endpoint in-hospital major adverse cardiac and cerebrovascular events (MACCE) were also very low (0.6 % vs. 0.9 % vs. 0.9 %; p < 0.001) but significantly higher in elderly patients with no further increase in the very elderly patient group.

CONCLUSION

We found no differences in this registry in intraprocedural complications during elective PCI between younger and elderly patients. Although in-hospital MACCE were somewhat higher in the elderly, the overall event rate was low and thus elderly patients should not be deprived from this therapy because of age alone.

Comparison of outcomes of patients ≥ 80 years of age having percutaneous coronary intervention according to presentation (stable vs unstable angina pectoris/non-ST-segment elevation myocardial infarction vs ST-segment elevation myocardial infarction)

Patients ≥ 80 years old with coronary artery disease constitute a particular risk group in relation to percutaneous coronary intervention (PCI). From 2002 through 2008 we examined the annual proportion of patients ≥ 80 years old undergoing PCI in western Denmark, their indications for PCI, and prognosis. From 2002 through 2009 all elderly patients treated with PCI were identified in a population of 3.0 million based on the Western Denmark Heart Registry. Cox regression analysis was used to compare mortality rates according to clinical indications controlling for potential confounding. In total 3,792 elderly patients (≥ 80 years old) were treated with PCI and the annual proportion increased from 224 (5.4%) in 2002 to 588 (10.2%) in 2009. The clinical indication was stable angina pectoris (SAP) in 30.2%, ST-segment elevation myocardial infarction (STEMI) in 35.0%, UAP/non-STEMI in 29.7%, and "ventricular arrhythmia or congestive heart failure" in 5.1%. Overall 30-day and 1-year mortality rates were 9.2% and 18.1%, respectively. Compared to patients with SAP the adjusted 1-year mortality risk was significantly higher for patients presenting with STEMI (hazard ratio 3.86, 95% confidence interval 3.08 to 4.85), UAP/non-STEMI (hazard ratio 1.95, 95% confidence interval 1.53 to 2.50), and ventricular arrhythmia or congestive heart failure (hazard ratio 2.75, 95% confidence interval 1.92 to 3.92). In patients with SAP target vessel revascularization decreased from 7.1% in 2002 to 2.5% in 2008. In conclusion, the proportion of patients ≥ 80 years old treated with PCI increased significantly over an 8-year period. Patients with SAP had the lowest mortality rates and rates of clinically driven target vessel revascularization decreased over time.

Procedural and long-term outcome of primary percutaneous coronary intervention in octogenarians

Background/objectives. To investigate the procedural and long-term outcome of primary percutaneous coronary intervention (PCI) in octogenarians with an acute myocardial infarction.Methods. We performed a retrospective analysis of all consecutive octogenarian patients (n=98) with an acute myocardial infarction treated with primary PCI in the Catharina Hospital in the year 2006. We compared procedural results and outcome with a matched control group composed of non-octogenarians undergoing primary PCI. Follow-up period was one year.Results. The initial success rate of PCI was similar in the two groups but short-term mortality was higher among the elderly patients: 30-day mortality 26.3 vs. 9.6%. Age-adjusted mortality between 30 days and one year was comparable in the two groups and similar to natural survival in the Netherlands. Octogenarians were less likely to have a normal left ventricular function during follow-up (48.3 vs. 66.7%). New York Heart Association (NYHA) class and recurrence rate of myocardial infarction was higher among octogenarians.Conclusion. Technical success rate during primary PCI was as good for octogenarians as in younger patients, but 30-day mortality, though acceptable, was higher among the elderly. After 30 days, age-adjusted mortality was comparable in both groups. (Neth Heart J 2010;18:129-34.).

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.

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.

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.).

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.

Special issues when caring for the older person with acute coronary syndromes

Persons 75 years of age or older constitute 6% of the US population but account for more than one third of those with acute coronary syndromes (ACS). Unfortunately, most randomized clinical trials have enrolled few older persons, and, as a result, few data are available to guide clinical practice. As in younger patients, aspirin, beta-blockers, nitrates, clopidogrel, heparin, statins, and angiotensin-converting enzyme inhibitors are useful, beginning with lower doses and carefully observing the patient for symptoms of toxicity. Similarly, older patients should not be denied the benefit of reperfusion therapy and early invasive strategy because of their age. Although primary angioplasty is an optimal reperfusion strategy, thrombolytic therapy is a beneficial alternative in carefully selected older patients. Although glycoprotein IIb/IIIa inhibitors appear to be beneficial in select cases, bleeding concerns exist. Despite a growing body of evidence in support of aggressive ACS care in older persons, evidence-based therapy is underused in older patients. Continued efforts are required to improve the quality of care to this high-risk cohort of ACS patients.

Effectiveness of percutaneous coronary interventions in nonagenarians

Data on percutaneous coronary intervention (PCI) in nonagenarians are very scarce. The investigators present a series of 26 nonagenarians who underwent PCI (29 lesions, 1.1 +/- 0.3 per patient). Most (96%) had acute coronary syndrome at presentation, 27% underwent primary PCI for acute myocardial infarctions, and 54% had multivessel disease. Angiographically successful results were obtained in 24 patients (92%), and coronary stents were used in 81%. Five patients (19%) died during hospitalization. In-hospital mortality was significantly greater in patients with Killip class III or IV at presentation (100% vs 9%, p = 0.001), in those in whom the procedure was a primary PCI for acute myocardial infarction (57% vs 5%, p = 0.010), and in the presence of angiographic failure (100% vs 13%, p = 0.031). In-hospital mortality was 0% after excluding patients in cardiogenic shock and those with primary PCI. Thus, most nonagenarians who undergo PCI have a high-risk profile. However, PCI achieves a successful angiographic result in most patients. Mortality is high but concentrated in patients in cardiogenic shock and with primary angioplasty as PCI.

Comparison of treatment outcomes in patients > or =80 years undergoing transradial versus transfemoral coronary intervention

We assessed the effect of transradial access (vs transfemoral access) for percutaneous coronary intervention on postprocedure length of stay and patient outcomes (in-hospital complications and all-cause and cardiac death at 6 and 12 months) in 225 elderly patients (> or =80 years old). Raw differences between transradial and transfemoral accesses were compared, and 3 forms of propensity score analysis were used to determine the true effect of transradial access. After matching to adjust for baseline differences in patient characteristics, remaining differences in outcomes and postprocedure length of stay were small and not statistically significant at the 95% level, but a decrease in postprocedural length of stay of nearly 1 day was observed and likely was not due to chance. Transradial access in patients > or =80 years old undergoing percutaneous coronary intervention should be preferred due to equivalent success rate and safety and likely reduction in postprocedural hospitalization.

Sex differences in hospital mortality after coronary artery bypass surgery: evidence for a higher mortality in younger women

BACKGROUND

Data are conflicting over whether women have higher mortality than men after coronary artery bypass graft (CABG) surgery. Younger but not older women hospitalized for acute myocardial infarction have higher in-hospital mortality rates than men. We hypothesized that younger women also have higher in-hospital mortality rates after CABG.

METHODS AND RESULTS

We studied 51 187 patients (30% women) included in the National Cardiovascular Network database who received CABG at 23 clinical centers between October 1993 and December 1999. Compared with men, fewer women were white and more women had risk factors and comorbidities. These differences were more apparent in younger patients. In all age groups, however, women had higher left ventricular ejection fraction and fewer diseased vessels. Women had higher in-hospital mortality rates than men, but sex differences in mortality were more marked among younger patients. Women <50 years of age were 3 times more likely to die than men (3.4% versus 1.1%), and women 50 to 59 years of age were 2.4 times more likely to die than men (2.6% versus 1.1%). In the older age categories, the sex difference in in-hospital mortality was less marked (P<0.001 for the interaction between sex and age). Adjustment for preoperative risk factors only slightly decreased the strength of this interaction.

CONCLUSIONS

Younger women undergoing CABG surgery are at a higher risk of in-hospital death than men, but this difference in risk decreases with advancing age. Additional investigation is needed to determine why in-hospital mortality is higher in women after CABG, with particular focus on younger women.