Complex, high-risk percutaneous coronary intervention types, trends, and in-hospital outcomes among different age groups: An insight from a national registry

BACKGROUND

Complex, high-risk percutaneous coronary intervention (PCI) (CHiP) is increasingly being undertaken in octogenarians. However, limited data exist on CHiP types, trends, and outcomes in the octogenarian.

METHODS

This is a retrospective cohort study from a national registry dataset on CHiP undertaken in patients with stable angina in England and Wales (January 2006 and December 2017) according to three age groups (group 1 [G1]: < 65 years; group 2 [G2]: 65-79 years; and group 3 [G3]: ≥80 years).

RESULTS

Of 424,290 elective PCI procedures, 138,831 (33.0%) were CHiP [G1: 46,832 (33.7%); G2: 59,544 (42.9%); G3: 32,455 (23.4%)]. Among CHiP types, chronic total occlusion (CTO) (49.2%), prior coronary artery bypass graft (CABG) (30.4%), and severe vascular calcification (21.8%) were common in G1; prior CABG (42.9%), CTO (32.9%), and severe vascular calcifications (27%) were common in G2; prior CABG (15.8%), severe vascular calcification (15.5%), and chronic renal failure (11.1%) were common CHiP among the octogenarians. The older age groups had higher adjusted odds (aOR) for adverse outcomes [G2: mortality, aOR 1.7, 95% confidence interval (CI): (1.3-2.3); major bleeding, aOR 1.3, 95% CI (1.1-1.5); MACCE, aOR 1.2, 95% CI (1.0-1.3); G3: mortality, aOR 2.6, 95%CI (1.9-3.6); major bleeding, aOR 1.4, 95% CI (1.1-1.7); MACCE, aOR 1.3, 95% CI (1.1-1.5)].

CONCLUSION

There were significant differences in the types of CHiP cases undertaken and clinical outcomes across age groups.

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.

Comparison of long-term outcomes of medical therapy and successful recanalisation for coronary chronic total occlusions in elderly patients: a report of 1,294 patients

Background

Little is known about the long-term outcomes of medical therapy (MT) versus successful percutaneous coronary intervention (PCI) in elderly patients with coronary chronic total occlusions (CTOs).

Methods

There were 1,294 consecutive patients with 1,520 CTOs included (2007 to 2016) and were divided into the younger group (age <65 years; n=664, 51.3%) and the older group (age ≥65 years; n=630, 48.7%). In the older group, 630 patients were divided into MT group (n=421) and successful CTO-PCI group (n=209) according to the initial treatment strategy. In the younger group, they were divided into two groups: 379 patients in the MT group and 285 patients in the successful CTO-PCI group. We performed propensity score matching to minimize any selection bias. The primary end point was cardiac mortality. The secondary end point was major adverse cardiac event (MACE).

Results

After 3.6 (IQR, 2.1-5.0) years follow-up, no significant difference was observed between the MT and successful CTO-PCI groups in terms of cardiac mortality (MT vs. successful CTO-PCI: 9.3% vs. 5.0%, P=0.378) and MACE (28.3% vs. 15.1%, P=0.070) in the older group. After propensity score matching analysis (120 pairs), the risk of cardiac mortality (6.7% vs. 8.3%, P=0.624) was found to be comparable between the two groups. In the younger group, the occurrence of cardiac death (MT vs. successful CTO-PCI: 3.7% vs. 1.4%, P=0.072) was similar, whereas the MACE rate (27.7% vs. 17.9%, P=0.003) was significantly higher in MT group. After multivariate analysis, previous myocardial infarction (MI) [hazard ratio (HR) 1.70, 95% confidence interval (CI): 1.16-2.49, P=0.006], CTO in right coronary artery (HR 1.55, 95% CI: 1.07-2.25, P=0.020), multivessel disease (HR 2.02, 95% CI: 1.10-3.72, P=0.024) and calcification (HR 1.61, 95% CI: 1.07-2.42, P=0.023) were independent predictors of MACE in elderly.

Conclusions

In the treatment of elderly patients with CTOs, successful CTO-PCI compared with MT alone didn't reduce the risk of cardiac death or MACE.

Current approaches for treatment of coronary chronic occlusions

Introduction: Coronary chronic total occlusions (CTO) represent a challenging subset in interventional cardiology.Areas covered: During the last decade, improvements in materials, techniques, and meticulous pre-procedural lesion assessment have increased the success rate in CTO lesions. Several scores have been developed to address overall lesion evaluation and help select the most appropriate treatment strategy. In addition, specific algorithms such as the hybrid algorithm have been introduced to provide a framework for CTO operators and a rapid management of the various challenging aspects of the procedure. The hybrid approach requires operator's ability to switch from one treatment strategy to another when the first one appears to be unsuccessful. Adequate training and operators' experience remain crucial to improve the likelihood of success.Expert opinion: The aim of this review is to provide insights and guidance for operators on current approaches for treatment of CTO and complication management.

Duration of dual antiplatelet therapy in patients treated with percutaneous coronary intervention for coronary chronic total occlusion

Background

The duration of dual antiplatelet therapy (DAPT) after drug-eluting stent implantation in coronary chronic total occlusion (CTO) remains unclear.

Methods

We retrospectively analyzed a total of 512 patients treated with percutaneous coronary intervention (PCI) in the Samsung Medical Center CTO registry. Patients were separated into ≤ 12-month (199, 38.9%) vs. > 12 month (313, 61.1%) based on DAPT duration with aspirin and clopidogrel. The primary outcome was major adverse cardiac and cerebrovascular event (MACCE) during follow-up.

Results

Median follow-up duration was 67 (interquartile range: 51–84) months. MACCE occurred in 43 patients (21.6%) in the ≤ 12-month and 55 patients (17.6%) in the > 12-month groups. In the propensity-matched population, the rate of MACCE did not differ significantly between the ≤ 12-month and > 12-month group (19.4% vs. 18.8%; hazard ratio [HR], 0.95; 95% confidential interval [CI], 0.52–1.76, p = 0.88). Moreover, moderate or severe bleeding according to BARC criteria (type 2, 3 or 5) was also similar between the ≤ 12-month and > 12-month group (2.5% vs. 1.9%; HR, 1.00; 95% CI, 0.20–4.96, p = 0.99).

Conclusion

Among patients treated with PCI for CTO, DAPT with durations of ≤ 12-month showed similar long-term clinical outcomes compared to > 12-month DAPT.