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

Short and Long-Term Clinical Outcomes in Octogenarian Patients With Non-ST-Elevation Myocardial Infarction: A Comparative Analysis of Revascularization Strategies Versus Medical Management

INTRODUCTION

As the primary cause of morbidity and mortality among older individuals, cardiovascular disease remains a major concern. Choosing between revascularization and medical management of elderly patients remains controversial. This study aims to evaluate the clinical implications of these treatment approaches in the context of non-ST-elevation myocardial infarction (NSTEMI) in octogenarian patients.

METHODS

This observational cohort study involved 41 octogenarian patients who were diagnosed with NSTEMI from 2019 to 2021 and were managed by revascularization (with either percutaneous coronary intervention, coronary artery bypass graft surgery, or both) or conservative medical therapy. All NSTEMI patients were diagnosed based on symptoms, electrocardiographic changes, and cardiac biomarkers. The study compared the short- and long-term outcomes of 13 patients in the revascularization group and 28 in the medical therapy group.

RESULTS

Overall, the mean patient age was 84.63 years. Eighteen patients were men (43.9%), and 23 were women (56.1%). The most prevalent disease among the sample was hypertension (34 patients, 82.9%), followed by diabetes mellitus (27 patients, 65.9%) and prior ischemic heart disease (21 patients, 51.2%). Almost all patients in the revascularization-treated group developed complications after the procedure (84.6%), while 46.4% of the patients in the medication-only group developed a complication later on. The revascularization-treated group showed higher mortality rates in both the short- and long-term (23.1% and 38.5%, respectively) compared to the medication-only group, which showed better survival rates numerically in both the short- and long-term (14.3% and 32.1%, respectively). This was not statistically significant.

CONCLUSION

Revascularization treatment in elderly patients with NSTEMI was associated with a higher risk of complications and a higher mortality rate compared with conservative medical management. Patients managed with only medications had a better survival rate in both the short- and long-term.

Contemporary Trends in Clinical Characteristics, Therapeutic Strategies and Outcomes in Patients Aged 80 Years and Older Presenting with non-ST Elevation Myocardial Infarctions in the United States

The current guidelines for the management and treatment of acute coronary syndromes do not fully consider the role of age in guiding medical or invasive management. We investigated the characteristics, management strategies, and clinical outcomes of patients aged 80 years and older presenting with non-ST elevation myocardial infarction (NSTEMI). A cohort study using the nationwide inpatient sample database of patients aged 80 years and older presenting with NSTEMI in the United States between 2012 to 2018 was performed. About 24.2% (151,472/625,916) of NSTEMI patients were 80 years and older. Older patients (≥80 years) had higher in-hospital mortality and cardiovascular complications compared to younger patients (odds ratio (OR) 1.79, 95% confidence intervals (CI) 1.71-1.88, P < 0.001). Among older patients, conservative medical management was associated with higher inpatient mortality compared to percutaneous coronary intervention (PCI) (OR 2.3, 95% CI 2.18-2.41, P < 0.001) or coronary artery bypass graft (CABG) (OR 1.9, 95% CI 1.76-2.09, P < 0.001). The highest mortality rate was observed in older patients who underwent both PCI and CABG, followed by those treated conservatively and those undergoing coronary angiography without revascularization. This study provides valuable insights into the clinical characteristics and outcomes of elderly patients presenting with NSTEMI in the United States. The results emphasize the importance of a tailored approach to the management of ACS in elderly patients and the need for improved revascularization strategies to reduce in-hospital mortality and adverse cardiovascular outcomes. Therefore, the clinician should tailor the management of older patients presenting with NSTEMI.

Complex Percutaneous Coronary Intervention Outcomes in Older Adults

Background Complex percutaneous coronary intervention (PCI) is increasingly performed in older adults (age ≥75 years) with stable ischemic heart disease. However, little is known about clinical outcomes. Methods and Results We derived a cohort of older adults undergoing elective PCI for stable ischemic heart disease across a large health system. We compared 12-month event-free survival (freedom from all-cause death, nonfatal myocardial infarction, stroke, and major bleeding), all-cause death, target lesion revascularization, and bleeding events for patients receiving complex versus noncomplex PCI and derived risk estimates with Cox regression models. We included 513 patients (mean age, 81±5 years). Patients receiving complex PCI versus noncomplex PCI did not significantly differ across a host of clinical characteristics including cardiovascular disease features, noncardiac comorbidities, guideline-directed medical therapy use, and frailty. Patients receiving complex PCI versus noncomplex PCI experienced worse event-free survival (80.4% versus 86.8%), which was not significant in adjusted analyses (hazard ratio [HR], 1.38 [95% CI, 0.88-2.16]). All-cause death at 1 year for patients undergoing complex PCI was nearly double that seen for patients receiving noncomplex PCI (10.2% versus 5.9%), and the risk was significant in models adjusted for clinical characteristics (HR, 1.97 [95% CI, 1.02-3.79]). Target lesion revascularization risk was lower for patients receiving complex PCI (2.2% versus 3.5%, adjusted HR), but bleeding events were not statistically different between groups (25.3% versus 20.5%; P=0.19). Conclusions Complex PCI in older adults with stable ischemic heart disease was associated with lower risk of target lesion revascularization but higher all-cause death compared with noncomplex PCI.

Outcomes of Percutaneous Coronary Intervention in Elderly Patients with Rheumatoid Arthritis: A Nationwide Population-Based Cohort Study

Rheumatoid arthritis (RA) increases the risk of cardiovascular disease. This study aimed to evaluate the clinical outcomes of elderly patients with and without RA who underwent percutaneous coronary intervention (PCI). The Korean National Health Insurance Service claims database was used to extract data on 74,623 patients (14,074 with RA and 60,549 without RA) aged ≥ 65 years who were diagnosed with acute coronary syndrome and underwent PCI between 2008 and 2019. The primary outcome was survival of elderly patients with and without RA. The secondary outcome was survival in the RA subgroup. During a 10-year follow-up, the all-cause mortality survival rate was lower in patients with RA than that in patients without (53.7% vs. 58.3%, respectively, log-rank: p < 0.001). In the all-cause mortality RA subgroup, patients with elderly-onset RA had poor survival outcomes, whereas patients with young-onset RA had good survival outcomes compared with that in patients without RA (48.1% vs. 73.7% vs. 58.3%, respectively, log-rank: p < 0.001). Elderly patients with RA who underwent PCI had an increased mortality risk, particularly those with elderly rather than young-onset RA.

The independent impact of dementia in patients undergoing percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

Although age and frailty are associated with worse prognoses for patients who undergo percutaneous coronary intervention (PCI), little is known regarding the independent impact of dementia.

HYPOTHESIS

The aim of this study was to evaluate the association between dementia and outcomes for patients with acute myocardial infarction (AMI).

METHODS

Consecutive patients with ST-elevation or non-ST elevation MI who had undergone PCI as part of our AMI registry were included in this study. We compared outcomes within the 1-year period of their PCI, including death and major adverse cardiac events (MACE) and corrected for confounders using Cox regression.

RESULTS

Of 28 274 patients, 9167 patients who had undergone PCI for AMI were included in this study, 250 with dementia; Mean age (77.4 ± 9.4 in the dementia group vs. 63.6 ± 12.7 in the control), female gender (32.4 vs. 24.2%, p = .003), diabetes mellitus (54.0 vs. 42.4%, p < .001) and chronic kidney disease (44.4 vs. 19.3%, p < .001) were higher. At 12 months, unadjusted rates of death (25.5 vs. 9.8%, p < .001) and MACE (33.8 vs. 17.6%, p < .001) were higher for patients with dementia. After standardizing for confounding variables, dementia remained an independent risk factor for death (HR 1.90; CI 1.37-2.65; p < .001) and MACE (HR 1.73; CI 1.30-2.31; p < .001), as well as in propensity score matched analysis (HR 1.54; CI: 1.03-2.28; p < .001 and HR 1.49; CI: 1.09-2.02; p < .001, respectively).

CONCLUSIONS

Dementia is an independent predictor of worse outcomes in patients undergoing PCI for AMI. Future intervention and specialized healthcare measures to mitigate this risk is warranted.

Emergency coronary angiography in a 90-plus population: outcomes at 5-year follow-up

Elderly people represent a vulnerable and increasing population presenting with acute coronary syndrome (ACS). Our goal was to evaluate a group of very old patients who underwent emergency coronary angiography (CA). We retrospectively analyzed a group of very old patients (≥90 years old) who underwent emergency CA from 2008 to 2020. Survival and major adverse cardiovascular events (MACE) (a composite of all-cause death, ischemic stroke, ACS, or hospitalization for acute heart failure) were compared with an aged-matched control population with ACS not submitted to emergency CA. A total of 34 patients were enrolled, 56% of whom were female, with a median age of 92 years old. Almost all patients had ST elevation-ACS. In CA, 65% had multivessel disease, and coronary intervention was performed in 71%. More than one-third evolved in Killip class III/IV, and 70% had left ventricular dysfunction. Regarding mortality, 38% of patients died in the index event versus 25% in the aged-matched control group (p=0.319). During 5 years of follow-up, there was no significant difference in mortality between the 2 groups (Log-rank=0.403) and more than 50% of patients died in 2 years. Comparing MACE occurrence, both groups were similar (Log-rank=0.662), with more than 80% having at least one event in 5 years. Very old patients submitted to emergency CA had a high rate of multivessel disease and left ventricular dysfunction, in-hospital and follow-up mortality, and MACE. Compared to an aged-matched control group not submitted to emergency CA, they showed no survival or MACE benefit during a 5-year follow-up.

Utilization Rate and Outcomes of Intravascular Imaging in Elderly Patients Presenting With ST-Elevation Myocardial Infarction

BACKGROUND

Elderly patients presenting with ST-elevation myocardial infarction (STEMI) represent a vulnerable population with comorbid conditions and complex coronary anatomy. We aimed to describe the utilization rate and outcomes of intravascular imaging to guide percutaneous coronary intervention (PCI) in this population.

METHODS

The Nationwide Readmissions Database was queried for all hospitalizations for STEMI involving PCI from 2018 to 2019. Hospitalizations were stratified by patient age into a younger cohort <75 years (mean age 58.7 ± 9.5 years) and an older cohort ≥75 years. Propensity score-weighed regression analysis was used to identify the association of intravascular imaging with in-hospital mortality, 90-day all-cause readmission, and readmission for myocardial infarction (MI).

RESULTS

A total of 299,619 STEMI PCI hospitalizations were included. Intravascular imaging was utilized less frequently in the older cohort (6.8 % vs 7.8 %, odds ratio [OR] 0.87, 95 % CI 0.82-0.92, p < 0.001). In both cohorts, intravascular imaging was more likely to be used with anterior STEMI, complex PCI, mechanical support, and thrombectomy. Propensity score analysis showed the use of intravascular imaging was associated with lower in-hospital mortality in both cohorts (OR 0.60, 95 % CI 0.52-0.68, p < 0.001 in the younger cohort and OR 0.61, 95 % CI 0.51-0.72, p < 0.001 in the older cohort). There was no difference in 90-day all-cause readmission or readmission for MI with intravascular imaging.

CONCLUSIONS

Intravascular imaging during STEMI PCI is associated with lower in-hospital mortality regardless of age. Further studies are needed to understand the low utilization rates especially among elderly patients.

Safety of clinical engineer-assisted percutaneous coronary intervention

Percutaneous coronary intervention (PCI) requires multiple staff members, including interventional cardiologists, with the physical burden of heavy protective measures to minimize radiation exposure. Here, we aimed to investigate the safety of task sharing with clinical engineers (CEs) working as 1st assistant during ad hoc PCI. We retrospectively included 286 patients who underwent ad hoc PCI following diagnostic catheterization for coronary artery disease between April 2019 and March 2021. Procedural complications including coronary perforation or rupture, myocardial infarction, cerebral embolism, cardiovascular death, decreased kidney function, and radiation parameters were compared between the two clinical settings [CE group, CEs as the 1st assistant from the beginning of diagnostic coronary angiography to the end of PCI vs. doctor (DR) group, others]. There was no increase in the ratio of procedural complications in the CE group (1.7%) versus the DR group (1.2%). Fluorescence time and radiation exposure dose were significantly reduced in the CE group {25 min [interquartile range (IQR), 19-35 min] vs. 28 min (IQR, 20-39 min), P = 0.036; 908 mGy (IQR, 654-1326 mGy) vs. 1062 mGy (IQR, 732-1594 mGy), P = 0.049}. The median amount of contrast medium was significantly reduced in the CE group [100 mL (IQR, 80-119 mL) vs. 110 mL (IQR 90-140 mL), P < 0.001]. After propensity matching, fluorescence time, radiation exposure dose, and contrast medium amount were similar between groups. Task sharing with CEs as the 1st assistant during ad hoc PCI could contribute to clinical safety in patients with coronary artery disease.

Impact of Comorbid Disease Burden on Clinical Outcomes of Female Acute Myocardial Infarction Patients

Owing to the paucity of information on the clinical outcomes in female patients with acute myocardial infarction (AMI) in relation to the comorbid disease burden, we explored the differences in their clinical outcomes and identified predictive indicators. A total of 3,419 female AMI patients were stratified into two groups: Group A (those with zero or one comorbid diseases) (n=1,983) and Group B (those with two to five comorbid diseases) (n=1,436). Five comorbid conditions were considered: hypertension, diabetes mellitus, dyslipidemia, prior coronary artery disease, and prior cerebrovascular accidents. The primary outcome was major adverse cardiac and cerebrovascular events (MACCEs). The incidence of MACCEs was higher in Group B than in Group A in both the unadjusted and propensity score-matched data. Among the comorbid conditions, hypertension, diabetes mellitus, and prior coronary artery disease were found to be independently associated with an increased incidence of MACCEs. Higher comorbid disease burden was positively associated with adverse outcomes in the female population with AMI. Since both hypertension and diabetes mellitus are modifiable and independent predictors of adverse outcomes after AMI, it may be necessary to focus on the optimal management of blood pressure and glucose levels to improve cardiovascular outcomes.

In-hospital outcomes and readmission in older adults treated with percutaneous coronary intervention for stable ischemic heart disease

Background

Percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) in older adults requires a meticulous assessment of procedural risks and benefits, but contemporary data on outcomes in this population is lacking. Therefore, we examined the risk of near-term readmission, bleeding, and mortality in high-risk cohort of older adults undergoing inpatient PCI for SIHD.

METHODS

We analyzed the National Readmissions Database from 2017 to 2018 to identify index hospitalizations in which PCI was performed for SIHD. Patients were stratified into those ≥ 75 years old (older adults) and those < 75 years old. The primary outcome was 90-day readmission. Secondary outcomes included in-hospital mortality, hospital length of stay (LOS), and total hospital charge.

RESULTS

A total of 74,516 patients underwent inpatient PCI for SIHD, of whom 24,075 were older adults. Older adult patients had higher odds of in-hospital mortality (OR = 2.00, 95% CI: 1.68-2.38), intracranial hemorrhage (OR = 2.03, 95% CI: 1.24-3.34), and gastrointestinal hemorrhage (OR = 1.72, 95% CI: 1.43-2.07) during index hospitalization, with longer LOS and in-hospital charge. Older adults also experienced a higher hazard of 90-day readmission for any cause (HR = 1.61, 95% CI: 1.57-1.66) and cardiovascular causes (HR = 1.84, 95% CI: 1.77-1.91).

CONCLUSION

Older adults undergoing inpatient PCI for SIHD were at increased risk for in-hospital mortality, periprocedural morbidities, higher cost, and readmissions compared with younger adults. Understanding these differences may improve shared decision-making for patients with SIHD being considered for PCI.

Chronic Total Occlusion Percutaneous Coronary Intervention in Patients With Prior Coronary Artery Bypass Graft: Current Evidence and Future Perspectives

Coronary chronic total occlusion (CTO), which occurs in 18. 4–52% of all patients referred for coronary angiography, represents one of the last barriers in coronary intervention. Approximately half of all patients with prior coronary artery bypass graft (CABG), who undergo coronary angiography, are diagnosed with coronary CTO. In fact, these patients often develop recurrent symptoms and events, necessitating revascularization. Currently, there is neither a consensus nor developed guidelines for the treatment of CTO patients with prior CABG, and the prognosis of these patients remains unknown. In this review, we discuss current evidence and future perspectives on CTO revascularization in patients with prior CABG, with special emphasis on clinical and lesion characteristics, procedural success rates, periprocedural complications, and long-term outcomes.

Outcomes of Nonagenarians with Acute Myocardial Infarction with or without Coronary Intervention

Percutaneous coronary intervention (PCI) is the mainstay treatment of acute myocardial infarction (AMI); however, many clinicians are reluctant to perform PCI in the elderly population. This study aimed to compare the clinical outcomes of PCI versus medical therapy in nonagenarian Korean patients with AMI. We compared the clinical outcomes of nonagenarian patients with AMI with or without PCI. From the pooled data, based on a series of Korean AMI registries during 2005−2020, 467 consecutive patients were selected and categorized into two groups: the PCI and no-PCI groups. The primary endpoint was 1-year major adverse cardiac event (MACE), a composite of all-cause death, non-fatal myocardial infarction, and any revascularization. Among the 467 participants, 68.5% received PCI. The PCI group had lower proportions of Killip classes III-IV, previous heart failure, and left ventricular ejection fraction <40%, but had higher proportions of all prescribed medications and STEMI diagnosis. The 1-year MACE and all-cause death were higher in the no-PCI group, although partially attenuated post-IPTW. Our study showed that nonagenarian patients with AMI undergoing PCI had better clinical outcomes than those without PCI. Nonetheless, further investigation is needed in the future to elucidate whether PCI is beneficial for this population.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Revascularization Strategies for Multivessel Coronary Artery Disease in the Elderly Population

BACKGROUND

Prospective trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of multivessel coronary disease (MVCAD) have included mostly younger patients. We compared treatment strategies in the elderly population.

MATERIALS AND METHODS

We performed a propensity-score-matched comparison of patients ≥75 y who underwent isolated CABG or PCI for MVCAD between 2011 and 2018, excluding those with prior cardiac surgery and/or significant left main disease. The primary outcome was 5-year Kaplan Meier survival, and secondary outcomes included readmissions and major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

Propensity-matching yielded 536 patients (266 PCI and 266 CABG). Rates of complete revascularization of all stenotic lesions were higher in the CABG arm (86.8% versus 21.8%; P < 0.001). Thirty-d mortality was similar between cohorts, though PCI recipients had shorter hospital stay and greater likelihood of discharge to home. Unadjusted one- (89.1% versus 88.4%) and 5-year (73.8% versus 60.1%) survival were both higher in patients who underwent CABG (P = 0.0332). Patients undergoing CABG had reduced, but nonsignificant cumulative incidence of all-cause hospital readmission and MACCE at 5 y. Subgroup analysis of patients 80 y or older revealed similar late survival benefit with CABG when compared to PCI. Among patients undergoing CABG, there did not appear to be any 5-year benefits from multi-arterial grafting.

CONCLUSIONS

Despite longer hospitalization and higher rate of nonhome discharge, CABG was associated with improved late survival over PCI in the elderly population. Cardiac surgeons should be included in the multidisciplinary evaluation of older patients with MVCAD.

Percutaneous Coronary Intervention Outcomes Based on Decision-Making Capacity

Background

Long‐term outcomes of percutaneous coronary intervention (PCI) based on patients’ decision‐making ability have not been studied. Our objective was to assess long‐term outcomes after PCI in patients who provided individual versus surrogate consent.

Methods and Results

Data were collected retrospectively for patients who underwent PCI at Cleveland Clinic between January 1, 2015 and December 31, 2016. Inclusion criteria consisted of hospitalized patients aged ≥20 years who had PCI. Patients with outpatient PCI, or major surgery 30 days before or 90 days after PCI, were excluded. Patients who underwent PCI with surrogate consent versus individual consent were matched using the propensity analysis. Kaplan–Meier, log rank, t‐statistic, and χ² tests were used for statistical analysis. The study was approved by the Institutional Review Board at Cleveland Clinic, Ohio. Of 3136 patients who underwent PCI during the study period, 183 had surrogate consent. Propensity matching yielded 149 patients from each group. Two‐year all‐cause mortality was significantly higher in the surrogate consent group (38 [25.5%] versus 16 [10.7%] deaths, log‐rank χ²=10.16, P<0.001). The 2‐year major adverse cardiac events rate was also significantly higher in the surrogate consent group (60 versus 36 events, log‐rank χ²=8.36, P=0.003).

Conclusions

Patients with surrogate consent had significantly higher all‐cause mortality and higher major adverse cardiac events when compared with patients with individual consent. This study emphasizes the fact that patients with an inability to give consent are at high risk and may need special attention in postprocedural and postdischarge care.

[Acute coronary syndrome in the elderly emergency department: diagnosis and management]

Acute coronary syndrome (ACS) is a pathology frequently encountered in emergency rooms, especially in the elderly. Caregivers must know how to recognize an ACS despite an often heterogeneous and atypical presentation. Management should include an overall assessment of the patient in order to decide on the best management for the patient.

Safety and efficacy of very short dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy in older patients undergoing percutaneous coronary intervention: meta-analysis of randomised controlled trials

BACKGROUND

older patients undergoing percutaneous coronary intervention (PCI) represent a growing population sharing both a high ischemic and bleeding risk. Dual antiplatelet therapy (DAPT) reduces the incidence of thrombotic events but exposes patients to an increased risk of bleeding and subsequent mortality. Its optimal duration after PCI remains unclear.

OBJECTIVE

to assess the impact of short-duration DAPT on both bleeding and ischemic events in the specific population of older patients undergoing PCI.

METHODS

we performed a meta-analysis of randomised controlled trials comparing the safety and efficacy of standard versus very short duration (≤ 3 months, followed by P2Y12 inhibitor monotherapy) DAPT after PCI with a drug-eluting stent in older patients.

RESULTS

four studies, representing 8,961 older patients, were finally included. Compared with standard duration, short-duration DAPT was associated with similar rates of major bleeding (relative risks, RR 0.70 [0.47; 1.05]) and the composite efficacy endpoint (RR 0.85 [0.63; 1.14]). There was a high level of heterogeneity between the studies (I2 = 68%) regarding major bleeding.

CONCLUSION

our meta-analysis suggests that short DAPT may be a valid option in older patients after PCI but it also highlights the need for specific studies in such patients on optimal duration of antiplatelet therapy.

Chronic total occlusion percutaneous coronary intervention in octogenarians and nonagenarians

OBJECTIVE

The outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in octogenarians and nonagenarians have received limited study.

METHODS

We compared in-hospital outcomes of CTO PCI between patients ≥80 vs. <80-years-old in 6233 CTO PCIs performed between 2012 and 2020 at 33 U.S. and international centers.

RESULTS

There were 415 octogenarians and nonagenarians in our study (7% of the total population). Compared with younger patients, octo- and nonagenarians were less likely to be men (73% vs. 83.2%, p < 0.0001) and more likely to have atrial fibrillation (27% vs. 12%, p < 0.0001) and prior coronary artery bypass graft surgery (CABG) (43% vs. 29%, p < 0.0001). They were more likely to have CTOs with moderate/severe calcification (71% vs. 46%, p < 0.0001), but had similar mean J-CTO scores (2.5 ± 1.3 vs. 2.4 ± 1.3, p = 0.08). They had lower technical and procedural success (82.2% vs. 86.3%, p = 0.0201; 80.3% vs. 84.8%, p = 0.016, respectively) and higher incidence of in-hospital major adverse cardiovascular events (3.4% vs. 1.8%, p = 0.021). On multivariable analysis PCI in octo- and nonagenarians was not independently associated with technical and procedural success or with in-hospital MACE.

CONCLUSION

CTO PCI is feasible in octo- and nonagenarians, although success rates are lower, and the risk of complications is higher compared with younger patients, likely related to more comorbidities and higher coronary lesion complexity.

Cerebrovascular events complicating cardiac catheterization - A tertiary care cardiac centre experience

Background:

Cerebrovascular events (CVEs) are one of the rare complications of cardiac catheterization. This prospective single-center study was conducted to assess the incidence, presentations, and outcomes of CVEs in patients undergoing cardiac catheterization.

Methods:

Patients undergoing cardiac catheterization who developed CVEs within 48 h of procedure were analyzed prospectively with clinical assessment and neuroimaging.

Results:

Out of 55,664 patients, 35 had periprocedural CVEs (0.063%). The incidence of periprocedural CVEs with balloon mitral valvotomy, percutaneous coronary intervention, and coronary angiography was 0.127%, 0.112%, and 0.043%, respectively. A larger proportion of periprocedural CVEs occurred in patients with acute coronary syndrome (ACS, 77.1%) than in patients with stable coronary artery disease (CAD). The majority of CVEs were ischemic type (33 patients, 94.3%). It was most commonly seen in the left middle cerebral artery (MCA) territory. Hemorrhagic CVEs were very rare (2 patients, 5.7%). The majority of the CVEs manifested during or within 24 h of the procedure (31 patients, 88.6%). Neurodeficits persisted during the hospital stay in 20 patients (57.2%), who had longer duration of procedure compared to those with recovered deficits (P = 0.0125). In-hospital mortality occurred in three patients (8.5%) and post-discharge mortality in another 3 (8.5%).

Conclusions:

Periprocedural CVEs are rare and have decreased over time. They occur in a greater proportion in patients with ACS than in patients with stable CAD, more with interventional than diagnostic procedures. Ischemic event in the left MCA territory is the most common manifestation, commonly seen within 24 h of the procedure. Longer duration of procedure was a risk factor for larger infarcts and hence persistent neurodeficit at discharge. Although a substantial number of patients recover the neurodeficits, periprocedural CVEs are associated with adverse outcomes.

Patient and Device Selection for Hemodynamic Support in High-Risk Percutaneous Coronary Intervention

Coronary artery disease continues to advance resulting in the development of high-risk percutaneous interventions. This includes treatment of patients with multivessel disease, unprotected left main, acute myocardial infarction complicated by cardiogenic shock, and depressed left ventricular ejection fraction. As a result, mechanical circulatory support devices have evolved but require an understanding of patient hemodynamics, device mechanics, and access management. Trial data regarding device selection are limited by inclusion of cardiogenic shock patients, and observational studies are conflicted by selection bias, site familiarity with devices, and complication management; therefore, clinical judgment is required to treat high-risk patients appropriately.

Revascularization versus drug therapy for coronary artery disease in patients aged over 80 years: a real-world study

Background

Revascularization for the treatment of coronary artery disease (CAD) is advancing rapidly and is used increasingly in old patients. This study aimed to compare the efficacy and safety of revascularization with drug therapy in CAD patients aged over 80 years at a real-world clinical setting.

Methods

A total of 501 CAD patients aged over 80 years were consecutively enrolled from January 2011 to January 2016 in Anzhen Hospital (Beijing, China), Capital Medical University. The patients were treated with percutaneous coronary intervention (PCI) (n=283), coronary artery bypass grafting (CABG) (n=106), or drug therapy (n=112). All-cause mortality, cardiovascular-related mortality, readmission rate, and Seattle Angina Questionnaire (SAQ) score were compared between the three treatment methods.

Results

A total of 411 patients (82.04%) were followed with a median duration of 25 months. All-cause mortality and cardiovascular-related mortality in the drug therapy group were significantly higher than the PCI and CABG groups (both P<0.05). Readmission rate for cardiovascular events in the CABG group was significantly lower than the PCI and drug therapy groups (both P<0.05). Scores of physical limitation, angina frequency, treatment satisfaction, and disease perception of the SAQ in the PCI and CABG groups were significantly higher than the drug therapy group (both P<0.05). Scores of angina stability did not differ significant between the three groups (P=0.127).

Conclusions

Revascularization is superior to drug therapy in efficacy and safety in the treatment of oldest-old patients with CAD.

Mechanical thrombectomy in stroke in nonagenarians: useful or futile?

BACKGROUND

Mechanical thrombectomy is the standard treatment in acute ischemic stroke due to large vessel occlusion, but there is limited evidence about its efficacy in very old patients. We sought to analyse safety and effectiveness of mechanical thrombectomy in nonagenarian versus octagenarian patients.

METHODS

We included consecutive patients with acute ischemic stroke due to large vessel occlusion subjected to mechanical thrombectomy, during 29 months in a tertiary center. Patients were divided into two sub-groups, according to age: 80-89 and >90 years old. Recanalization, complications, functional outcome and mortality at discharge and at 3 months were compared. Multivariable analysis was performed to identify independent predictors of functional outcome at 3 months of follow-up, assessed by the modified Rankin Scale.

RESULTS

A total of 128 octogenarians (88.9%) and 16 nonagenarians (11.1%) met the inclusion criteria. Successful revascularization was achieved in 87.5% of octagenarians and in 81.3% of nonagenarians (p = 0.486). Symptomatic hemorrhage occurred in 3.1% and 6.3% of younger and older patients, respectively (p = 0.520). Cerebral edema occured in 35.2% of octagenarians versus 25.0% of nonagenarians (p = 0.419). Functional independence (mRS ≤ 2) at 3 months was achieved in 28 (22.6%) and 5 (31.3%) of octagenarians and nonagenarians, respectively (p = 0.445). Mortality at 3 months was not significantly higher in nonagenarians (37.5%) versus octagenarians (33.9%, p = 0.773).

CONCLUSIONS

No significant diferences were found in functional outcome, mortality, recanalization and complication rates between octagenarians and nonagenarians submitted to mechanical thrombectomy, underlining that patients should not be excluded from mechanical thrombectomy based on age alone.

Percutaneous coronary intervention of unprotected left main and bifurcation in octogenarians: Subanalysis from RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life)

OBJECTIVE

Outcomes of complex percutaneous coronary interventions (PCIs) in older patients are still debated. The aim of the study was to evaluate clinical outcomes of Octogenarian patients treated with ultrathinstents on left main or on coronary bifurcations, compared with younger patients.

METHODS

All consecutive patients presenting a critical lesion of an unprotected left main (ULM) or a bifurcation and treated with very thin stents were included in the RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life) registry and divided into octogenarians group (OG, 551 patients) and nonoctogenarians (NOGs, 2,453 patients). Major adverse cardiovascular event (MACE), a composite end point of all-cause death, nonfatal myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST), was the primary endpoint, while MACE components, cardiovascular (CV) death, and target vessel revascularization (TVR) were the secondary ones.

RESULTS

Indication for PCI was acute coronary syndrome in 64.7% of the OG versus 53.1% of the NOG. Severe calcifications and a diffuse disease were significantly more in OG. After a follow-up of 15.2 ± 10.3 months, MACEs were higher in the OG than in the NOG patients (OG 19.1% vs. NOG 11.2%, p < .001), along with MI (OG 6% vs. NOG 3.4%, p = .002) and all-cause death (OG 14% vs. NOG 4.3%, p < .001). In contrast, no significant difference was detected in CV-death (OG 5.1% vs. NOG 4%, p = .871), TVR/TLR, or ST. At multivariate analysis, age was not an independent predictor of MACE (OR 1.02 CI 95% 0.76-1.38), while it was for all-cause death, along with diabetes, GFR < 60 ml/min, and ULM disease.

DISCUSSION

Midterm outcomes of complex PCI in OG are similar to those of younger patients. However, due to the higher non-CV death rate, accurate patient selection is mandatory.

Percutaneous Coronary Intervention in Elderly Patients with Coronary Chronic Total Occlusions: Current Evidence and Future Perspectives

The proportion of the elderly in the total population of the world is growing, and the number of elderly patients with coronary chronic total occlusions (CTO) is huge. The elderly patients often have more extensive coronary artery disease, more severe ischemic burden and higher risk of cardiovascular events, as compared to younger patients, and thereby they might greatly benefit from coronary revascularization, even though they may have higher risk of operative complications. Most interventional cardiologists are more likely to be reluctant to operate complex percutaneous coronary intervention (PCI) in elderly patients. The latest refinements in dedicated CTO-PCI equipment and techniques have led to high rates of success and low complications rates and have made the CTO-PCI procedures safe and effective among the elderly patients. However, up to now, there is no widely recognized consensus or guideline on treatment strategy of elderly CTO patients, and the prognosis in this population is unknown. In this review, we aim to provide an overview of the current evidence and future perspectives on PCI in elderly patients with CTOs.

Age-Dependent and -Independent Effects of Perivascular Adipose Tissue and Its Paracrine Activities during Neointima Formation

Cardiovascular risk factors may act by modulating the composition and function of the adventitia. Here we examine how age affects perivascular adipose tissue (PVAT) and its paracrine activities during neointima formation. Aortic tissue and PVAT or primary aortic smooth muscle cells from male C57BL/6JRj mice aged 52 weeks (“middle-aged”) were compared to tissue or cells from mice aged 16 weeks (“adult”). Vascular injury was induced at the carotid artery using 10% ferric chloride. Carotid arteries from the middle-aged mice exhibited smooth muscle de-differentiation and elevated senescence marker expression, and vascular injury further aggravated media and adventitia thickening. Perivascular transplantation of PVAT had no effect on these parameters, but age-independently reduced neointima formation and lumen stenosis. Quantitative PCR analysis revealed a blunted increase in senescence-associated proinflammatory changes in perivascular tissue compared to visceral adipose tissue and higher expression of mediators attenuating neointima formation. Elevated levels of protein inhibitor of activated STAT1 (PIAS1) and lower expression of STAT1- or NFκB-regulated genes involved in adipocyte differentiation, inflammation, and apoptosis/senescence were present in mouse PVAT, whereas PIAS1 was reduced in the PVAT of patients with atherosclerotic vessel disease. Our findings suggest that age affects adipose tissue and its paracrine vascular activities in a depot-specific manner. PIAS1 may mediate the age-independent vasculoprotective effects of perivascular fat.

Comparison of Outcomes After Percutaneous Coronary Interventions in Patients of Eighty Years and Above Compared With Those Less Than 80 Years

Life expectancy in the United States has increased due to advances in health care. Despite increased utilization of percutaneous coronary intervention (PCI), octogenarian patients are less likely to be referred to the catheterization laboratory for coronary interventions. This is in part due to multiple patient co-morbidities and lack of established guidelines. We examined in-hospital clinical outcomes of octogenarian and nonoctogenarian patients who underwent PCI in the United States. Using the National Inpatient Sampling database, we identified all adult patients who are older than 18 years and underwent PCI. Patient were stratified by age into 2 groups, ≥80 years old and <80 years old and in-hospital adverse outcome rates were determined. A total of 11,056,559 patients underwent PCI between the years of 2002 and 2014 and 1,544,563 patients were ≥80 years old (14%). After multivariable adjustment, patients who are ≥80 years old had higher in-hospital mortality (3.3% vs 1.3%, adjusted Odds Ratio, 1.624; 95% confidence interval, 1.602 to 1.647, p <0.0001) and longer length of stay (median length of stay days 3, range 2 to 8 days vs median 2 days, range 1 to 4 days) (p <0.0001). Patients ≥80 years old had a higher rate of cardiopulmonary complications, postprocedural stroke, acute kidney injury, postprocedural thromboembolic complications, and hemorrhage requiring transfusion. There was no difference in vascular complications between the 2 groups. In conclusion, octogenarians who underwent PCI were at increased risk for in-hospital mortality and morbidity compared with nonoctogenarians. The decision to proceed with PCI in this patient population should be individualized, taking into consideration known risk factors and patient's wishes.

Application of pulse index continuous cardiac output system in elderly patients with acute myocardial infarction complicated by cardiogenic shock: A prospective randomized study

BACKGROUND

Cardiogenic shock (CS) secondary to acute myocardial infarction (AMI) complicates management of the condition, and often leads to poor prognosis. Prompt and accurate monitoring of cardiovascular and accompanying hemodynamic changes is crucial in achieving adequate management of the condition. Advances in technology has availed procedures such as pulse index continuous cardiac output (PiCCO), which can offer precise monitoring of cardiovascular functions and hemodynamic parameters. In this study, PiCCO is evaluated for its potential utility in improving management and clinical outcomes among elderly patients with AMI complicated by CS.

AIM

To assess whether use of the PiCCO system can improve clinical outcomes in elderly patients with AMI complicated by CS.

METHODS

Patients from emergency intensive care units (EICU) or coronary care units (CCU) were randomized to receive PiCCO monitoring or not. The APACHE II score, SOFA score, hs-TnI, NT-proBNP, PaO₂/FiO₂ ratio and lactate levels on day 1, 3 and 7 after treatment were compared. The infusion and urine volume at 0-24 h, 24-48 h and 48-72 h were recorded, as were the cardiac index (CI), extravascular lung water index (EVLWI), intrathoracic blood volume index (ITBVI) and global end diastolic volume index (GEDVI) at similar time intervals.

RESULTS

Sixty patients with AMI complicated by CS were included in the study. The PiCCO group had a significantly lower APACHE II score, SOFA score, hs-TnI and NT-proBNP levels on day 1, 3 and 7 after treatment. The infusion and urine volume during 0-24 h in the PiCCO group were significantly greater, and this group also showed significantly higher ADL scores. Furthermore, the PiCCO group spent lesser days on vasoactive agents, mechanical ventilation, and had a reduced length of stay in EICU/CCU. Additionally, the CI was significantly higher at 48 h and 72 h in the PiCCO group compared with that at 24 h, and the EVLWI, ITBVI and GEDVI were significantly decreased at 48 h and 72 h.

CONCLUSION

Applying the PiCCO system could improve the clinical outcomes of elderly patients with AMI complicated by CS.

Periprocedural Myocardial Infarction in Contemporary Practice

"Periprocedural myocardial infarction (MI) occurs infrequently in the current era of percutaneous coronary interventions (PCI) and is associated with an increased risk of mortality and morbidity. Periprocedural MI can occur due to acute side branch occlusion, distal embolization, slow flow or no reflow phenomenon, abrupt vessel closure, and nonidentifiable mechanical processes. Therapeutic strategies to reduce the risk of periprocedural MI include dual antiplatelet therapy, intravenous cangrelor in the periprocedural setting, intravenous glycoprotein IIb/IIIa inhibitor in high-risk patients, anticoagulation with unfractionated heparin, low-molecular-weight heparin or bivalirudin, and embolic protection devices during saphenous vein graft interventions."

Comparison of Outcomes After Percutaneous Coronary Intervention in Elderly Patients, Including 10 628 Nonagenarians: Insights From a Japanese Nationwide Registry (J-PCI Registry)

Background Scarce data exist about the outcomes after percutaneous coronary intervention ( PCI ) in old patients. This study sought to provide an overview of PCI in elderly patients, especially nonagenarians, in a Japanese large prospective nationwide registry. Methods and Results We analyzed 562 640 patients undergoing PCI (≥60 years of age) from 1018 Japanese hospitals between 2014 and 2016 in the J-PCI (Japanese percutaneous coronary intervention) registry. Among them, 10 628 patients (1.9%), including 6780 (1.2%) with acute coronary syndrome ( ACS ) and 3848 (0.7%) with stable coronary artery disease, were ≥90 years of age. We investigated differences in characteristics and in-hospital outcomes among sexagenarians, septuagenarians, octogenarians, and nonagenarians. Older patients were more frequently women and had a greater frequency of heart failure and chronic kidney disease than younger patients. In addition, older patients had a higher rate of in-hospital mortality, cardiac tamponade, cardiogenic shock after PCI , and bleeding complications requiring blood transfusion. Nonagenarians had the highest risk of in-hospital mortality (odds ratio, 3.60; 95% CI , 3.10-4.18 in ACS ; odds ratio , 6.24; 95% CI, 3.82-10.20 in non- ACS ) and bleeding complications ( odds ratio, 1.79; 95% CI, 1.35-2.36 in ACS ; odds ratio , 2.70; 95% CI, 1.68-4.35 in non- ACS ) when referenced to sexagenarians. More important, transradial intervention was an inverse independent predictor of both in-hospital mortality and bleeding complications. Conclusions Older patients, especially nonagenarians, carried a greater risk of in-hospital death and bleeding compared with younger patients after PCI . Transradial intervention might contribute to risk reduction for periprocedural complications in elderly patients undergoing PCI .

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.

Predictors of In-Hospital Mortality in Korean Patients with Acute Myocardial Infarction

Acute myocardial infarction (AMI) is a fatal cardiovascular disease, and mortality is relatively high; therefore, integrated assessment is necessary for its management. There are several risk predictive models, but treatment trends have changed due to newly introduced medications and the universal use of percutaneous coronary intervention (PCI). The author aimed to find out predictive factors of in-hospital mortality in Korean patients with AMI. A group of 13,104 patients with AMI enrolled in the Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) registry were divided into two groups. One was a derivation group for evaluating mortality prediction; the other was a validation group for the application of risk prediction. In-hospital mortality was 4.2% (n=552). With hierarchical and stepwise multivariate analyses, nine factors were shown to predict in-hospital mortality for Korean patients with AMI. These were 1) being over 65 years of age, 2) high Killip class over II, 3) hyperglycemia over 180 mg/dl, 4) tachycardia over 100/min, 5) serum creatinine over 1.5 mg/dl, 6) atypical chest pain, 7) low systolic blood pressure under 90 mmHg, 8) low Thrombolysis In Myocardial Infarction (TIMI) flow (TIMI 0-II) before PCI and 9) low TIMI flow (TIMI 0-II) after PCI. The validation group showed a predictive power of 88.3%. Old age, high Killip class, hyperglycemia, tachycardia, renal dysfunction, atypical chest pain, low systolic blood pressure, and low TIMI flow are important risk factors of in-hospital mortality in Korean patients with AMI.

The prognostic value of mean platelet volume to platelet count ratio in older patients with non-ST elevation acute coronary syndrome receiving primary percutaneous coronary intervention: a retrospective study

BACKGROUND

The aim of this study was to investigate the value of the mean platelet volume to platelet count (MPV/P) ratio for predicting in-hospital and long-term cardiac mortality in older non-ST elevation-acute coronary syndrome (NSTE-ACS) patients after primary percutaneous coronary intervention (PCI).

METHODS

We retrospectively reviewed 452 older NSTE-ACS patients who received primary PCI. The patients were divided into two groups based on MPV/P ratios: high MPV/P group (N.=150) defined as a value in the third tertile (>0.056628) and low MPV/P group (N.=302) in the lower two tertiles (≤0.056628). Clinical outcomes included non-fatal reinfarction, heart failure, and cardiac mortality.

RESULTS

Multivariate analyses showed that high MPV/P and MPV values were independent predictors of cardiac mortality. The in-hospital cardiac mortality of the high MPV/P group was higher than the low MPV/P group (1.3% vs. 14.7%, P<0.001). The rates of heart failure and cardiac mortality in one year were significantly higher in the high MPV/P group compared to the low MPV/P group (P<0.05). The cut-off value of MPV/P for predicting cardiac death was 0.067107, with a sensitivity of 0.707 and a specificity of 0.868. MPV/P was superior to MPV (z=9.235, P<0.001) for predicting cardiac mortality.

CONCLUSIONS

High MPV/P and MPV values are independent predictors of cardiac mortality in older patients with NSTE-ACS receive primary PCI. Moreover, MPV/P is better than MPV for predicting cardiac mortality.

National Trends and Outcomes of Percutaneous Coronary Intervention in Patients ≥70 Years of Age With Acute Coronary Syndrome (from the National Inpatient Sample Database)

Several randomized trials have demonstrated the benefits of an invasive strategy for older patients with acute coronary syndromes (ACS); however, there are limited real-world data of the temporal trends in the use of percutaneous coronary intervention (PCI) in this population. This was a retrospective observational analysis. We queried the National Inpatient Sample database from 1998 to 2013 for patients aged ≥70 years who had non-ST-elevation acute coronary syndrome (NSTE-ACS) or ST-elevation myocardial infarction (STEMI). We reported the temporal trends of PCI and in-hospital mortality. A total of 6,720,281 hospitalizations with ACS were identified in advanced age patients, 18.3% of whom also underwent PCI. There was an upward trend in the rate of PCI in older adults ≥70 years with any ACS from 9.4% in 1998 to 28.3% in 2013 (p <0.001), as well as in cases of PCI for NSTE-ACS (7.3% in 1998 vs 24.9% in 2013, p <0.001) and PCI for STEMI (11% in 1998 vs 35.7% in 2013, p = 0.002). This upward trend was consistent in all age categories (70 to 79), (80 to 89) and ≥90 years. Despite an increase in the prevalence of comorbidities for ACS hospitalizations aged ≥70 years who received PCI, the in-hospital mortality rate showed a downward trend (p <0.001). Multivariate analysis adjusting for various comorbidities showed that PCI was associated with lower in-hospital mortality and length of hospital stay among elderly with NSTE-ACS and STEMI. In conclusion, in this 16-year analysis there was an increase in the rate of PCI procedures among older adults with ACS. PCI was independently associated with lower mortality in elderly patients with ACS.

Long-term outcomes and predictors of morbi-mortality according to age in stemi patients with multivessel disease: Impact of an incomplete revascularization

BACKGROUND

Optimal management strategy for patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) still remains unclear, especially in the elderly population. The aim of this study was to assess long-term outcomes and predictors of morbi-mortality according to age in patients with a STEMI and MVD.

METHODS

We prospectively included 381 consecutive patients with a STEMI who underwent primary angioplasty and showed MVD in the angiogram. 111 (29.1%) patients were older than 75 (≥75) years and 270 (70.9%) were younger than 75 (<75) years. The co-primary outcomes were the incidence of all-cause mortality and major adverse cardiac events (MACE) during follow-up.

RESULTS

During a median follow-up of 22 months, patients ≥75 years showed a higher incidence of all-cause mortality and MACE, as compared to younger patients. On multivariate analysis, incomplete revascularization (IR) was only an independent predictor of MACE (HR = 3.1, CI 95%:1.9-4.7; P = .02) in younger patients; whereas in the elderly group severely depressed ejection fraction was the unique independent predictor of MACE (HR = 2.7, CI 95%:1.5-4.8; P = .001). IR was not associated with the risk of all-cause mortality in any group.

CONCLUSION

This study confirms the relevant prevalence of MVD in STEMI patients, as well as the difference in outcomes of an IR strategy between both age-groups, being only independently associated with MACE in younger patients. This finding supports that a routine complete revascularization (CR) strategy seems to be the best therapeutic option in younguer patients, whereas in the elderly population may not confer a clear clinical benefit during a long-term follow-up.

[Radial approach in the elderly]

Due to the steady increase in life expectancy, the number of patients over 80 years of age proposed for coronary angioplasty is increasing significantly. The elderly patient is a patient at high cardiovascular risk and high risk of bleeding; whose severity of prognosis depends of comorbidities. The radial approach presents particularities and technical difficulties that have to be known in this part of the population, but reduce vascular and hemorrhagic complications, as well as mortality. Because of greater safety, the radial approach is therefore the first choice for the elderly.

Antiplatelet agents in uncertain clinical scenarios-a bleeding nightmare

Despite over 40 years since the first percutaneous coronary intervention (PCI) was performed, the optimal dual antiplatelet therapy (DAPT) regime poses a significant challenge for clinicians, especially in certain scenarios. DAPT is the standard of care in PCI following an acute coronary syndrome (ACS) or for elective patients with obstructive coronary artery disease (CAD). There remains significant uncertainty regarding DAPT in patients at high risk of bleeding, such as the elderly and patients requiring anticoagulation. More and more clinicians are faced with a dilemma of weighing risks and benefits from the increasing list of potent, new antiplatelet agents and direct oral anticoagulants (DOACs) in a growing, aging population. Historically, most studies failed to recognize bleeding risk, instead focusing on ischemic risk. In recent years however, bleeding has been recognized as a very significant driver of morbidity and mortality in patients undergoing PCI. There is a paucity of data in this cohort leading to divergent and sometimes conflicting recommendations, largely based on expert consensus of opinion. In the current review, we critically evaluate the available evidence in these uncertain scenarios.

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.

Outcomes of a percutaneous coronary intervention versus coronary artery bypass grafting in octogenarians

Background

The data on long-term outcomes for elderly patients with coronary artery disease who undergo invasive treatment is limited. This study aimed to assess long-term outcomes and risk factors for patients over 80 years of age who underwent revascularisation.

Methods

This single-centre retrospective study included ≥80-year-old patients who underwent coronary angiography between 2012 and 2014. Among 590 study patients, 411 patients had significant angiographic changes and had either a percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) performed. Baseline patient characteristics, including demographics, comorbidities, survival to hospital discharge, and long term mortality were analysed. Three-year mortality was assessed.

Results

Three hundred sixty-nine (89.8%) patients underwent PCI and in 42 (10.2%) CABG was performed. Significant differences between groups were detected in heart failure (PCI - 51.2% vs. CABG - 78.6%; p = 0.001), previous CABG (11.4% vs. 0%; p = 0.014), cardiogenic shock (12.2% vs. 0%; p = 0.008). Hospital mortality rate in the PCI group - 10.6%, CABG - 7.1%; p = 0.787. A median 3-year survival rate in the PCI group - 66.1%, CABG - 66.7%; p = 1.000. Chronic heart failure (OR 2.442; 95% CI: 1.530-3.898, p < 0.001), atrial fibrillation (OR 0.425; 95% CI: 0.261-0.692, p < 0.001), cardiogenic shock (OR 0.120; 95% CI: 0.054-0.270, p = 0.001), and LMCA stenosis (OR 2.104; 95% CI: 1.281-3.456, p = 0.003) were identified as independent 3-year all-cause mortality predictors in multivariate regression analysis.

Conclusions

There was no significant difference in hospital mortality and survival rates between elderly patients who underwent PCI or CAGB. The majority of elderly patients underwent a PCI and these patients appeared to experience cardiogenic shock more frequently.

Bleeding outcomes after non-emergency percutaneous coronary intervention in the very elderly

Background

Octogenarians constitute an increasing proportion of patients presenting for non-emergency percutaneous coronary intervention (PCI).

Methods

This study evaluated the in-hospital procedural characteristics and outcomes, including the bleeding events of 293 octogenarians presenting between January 2010 and December 2012 for non-emergency PCI to a single large volume tertiary care Australian center. Comparisons were made with 293 consecutive patients aged less than or equal to 60 years, whose lesions were matched with the octogenarians.

Results

Non-ST elevation myocardial infarction was the most frequent indication for non-emergency PCI in octogenarians. Compared to the younger cohort, they had a higher prevalence of co-morbidities and more complex coronary disease, comprising more type C and calcified lesions. Peri-procedural use of low molecular weight heparin (LMWH; 1.0% vs. 5.8%; P < 0.001) and glycoprotein IIb/IIIa inhibitors (2.1% vs. 9.6%; P < 0.001) was lower, while femoral arterial access was used more commonly than in younger patients (80.9% vs. 67.6%; P < 0.001). Overall, there was a non-significant trend towards higher incidence of all bleeding events in the elderly (9.2% vs. 5.8%; P = 0.12). There was no significant difference in access site or non-access site bleeding and major or minor bleeding between the two cohorts. Sub-analysis did not reveal any significant influence on bleeding rates by the use of LMWH, glycoprotein IIb/IIIa inhibitors or femoral arterial access. In addition, there were no significant differences in the rates of in-hospital mortality, stroke or acute stent thrombosis between the two groups.

Conclusions

In this single center study, we did not observe significant increases in adverse in-hospital outcomes including the incidence of bleeding in octogenarians undergoing non-emergency PCI.

Intraluminal Intensity of Blood Speckle on Intravascular Ultrasound, a Novel Predictor of Periprocedural Myocardial Injury After Coronary Stenting

The difference in the intraluminal intensity of blood speckle (IBS) on integrated backscatter-intravascular ultrasound (IB-IVUS) across a coronary artery stenosis (i.e., ΔIBS) has previously shown a negative correlation with fractional flow reserve, reflecting an impaired coronary blood flow. Periprocedural myocardial injury (PMI) after coronary stenting has also been associated with coronary circulatory dysfunction. The aim of this study was to investigate the relation between ΔIBS after coronary stenting and PMI. A total of 180 patients who underwent elective coronary stenting under IVUS guidance for a single lesion were included. Intraluminal IBS was measured using IB-IVUS in cross sections at the ostium of the target vessel and at the distal reference of the stent. ΔIBS was calculated as (distal IBS value) - (ostium IBS value). PMI was defined as an elevation of troponin I >5 times the 99th percentile upper reference limit (>0.45 ng/ml) within 24 hours after the procedure. The mean ΔIBS after coronary stenting was 6.52 ± 5.71. There was a significantly greater use of the rotational atherectomy, the number of stents, the total stent length, and ΔIBS in patients with PMI than those without. In the receiver operating characteristic curve analysis, ΔIBS significantly predicted PMI (area under the curve 0.64, best cut-off value 7.88, p = 0.001). Multiple logistic regression analysis determined that the total stent length, the use of rotational atherectomy, and ΔIBS were independent predictors of PMI. In conclusion, greater ΔIBS assessed by IB-IVUS was significantly associated with PMI after coronary stenting in patients with a stable coronary artery disease.