Incomplete revascularization in the drug eluting stent era permits meaningful long-term (12-78 months) outcomes in patients ≥ 75 years with acute coronary syndrome

Predictors of major adverse cardiac and cerebrovascular events after percutaneous coronary intervention in older adults: a systematic review and meta-analysis

AIM

We systematically reviewed and meta-analyzed the predictors of major adverse cardiac and cerebrovascular events (MACE/MACCE) in older adults who underwent PCI.

METHODS

Three databases, PubMed, Embase, and Scopus, were searched for observational studies considering the out-of-hospital MACE/MACCE in adults ≥ 60 years old with coronary artery disease (acute or chronic) who underwent PCI. Studies were eligible if they had determined at least two statistically significant predictors of MACE/MACCE by multivariable analysis. We used the QUIPS tool to evaluate the risk of bias in the studies. Random-effects meta-analysis was utilized to pool the hazard ratios (HRs) of the most reported predictors.

RESULTS

A total of 34 studies were included in the review. Older age (HR = 1.04, 95% Confidence Interval (CI): 1.03-1.06, P-value < 0.001), diabetes (HR = 1.36, 95% CI: 1.22-1.53, P < 0.001), history of myocardial infarction (MI) (HR = 1.88, 95% CI: 1.37-2.57, P < 0.001), ST-elevation MI (STEMI) at presentation (HR = 1.72, 95% CI: 1.37-2.18, P < 0.001), reduced left ventricular ejection fraction (LVEF) (HR = 2.01, 95% CI: 1.52-2.65, P < 0.001), successful PCI (HR = 0.35, 95% CI: 0.27-0.47, P < 0.001), eGFR (HR = 0.99, 95% CI: 0.97-1.00; P-value = 0.04) and left main coronary artery (LMCA) disease (HR = 2.07, 95% CI: 1.52-2.84, P < 0.001) were identified as predictors of MACE.

CONCLUSION

We identified older age, diabetes, history of MI, STEMI presentation, lower LVEF, and LMCA disease increased the risk of MACE/MACCE after PCI in older adults. Meanwhile, higher eGFR and successful PCI predicted lower adverse events risk. Future studies should focus on a more robust methodology and a precise definition of MACE.

REGISTRATION

PROSPERO (CRD42023480332).

Prognostic value of ΔSYNTAX% score in octogenarians undergoing percutaneous coronary intervention

OBJECTIVES

To verify whether incomplete revascularisation (IR), quantified using the rSYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score and ΔSYNTAX% score, could predict short- (in-hospital mortality) and long-term outcomes (12-month mortality) in octogenarians undergoing percutaneous coronary intervention (PCI).

METHODS & RESULTS

A retrospective analysis of 665 consecutive octogenarian patients presenting for PCI to a UK centre was performed. The baseline SYNTAX and rSYNTAX scores were assessed from angiographic images. ΔSYNTAX% score was calculated (ΔSYNTAX% = ((SYNTAX - rSYNTAX)/SYNTAX) × 100%)) to measure the relative completeness of revascularisation. Kaplan-Meier analysis assessed survival at 12 months by tertiles of rSYNTAX and ΔSYNTAX% scores. Increasing ΔSYNTAX% score was associated with reduced in-hospital mortality (P = 0.017), and improved survival benefit (log rank 14.8, P = 0.001) at 12 months.

CONCLUSIONS

Enhancing the completeness of revascularisation in octogenarians selected to undergo PCI is associated with a lower in-hospital mortality and a survival benefit at 12 months.

Residual SYNTAX Score and One-Year Outcome in Elderly Patients With Acute Coronary Syndrome

Background

The residual burden of coronary artery disease after percutaneous coronary intervention (PCI) has been associated with worse ischemic outcome. However, data are conflicting in elderly patients. The aim of our study was to verify the incremental value of the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (rSS) over clinical variables and baseline SYNTAX score (bSS) in predicting 1-year mortality or cardiovascular events.

Methods

A post hoc analysis of data collected in the Elderly-ACS 2 multicenter randomized trial was performed. We included 630 patients aged > 75 years with multivessel coronary disease undergoing PCI for acute coronary syndrome (ACS). The primary outcome was a composite of death, recurrent myocardial infarction, and stroke at 1-year follow up. Change in c-statistic and standardized net benefit were used to evaluate the incremental value of the rSS.

Results

Event rates were significantly higher in patients with incomplete revascularization (rSS > 8). When the rSS was included in a core Cox regression model containing age, previous myocardial infarction, and ACS type, the hazard ratio for patients with score values > 8 was 2.47 (95% confidence interval, 1.51-4.06). However, the core model with rSS did not increase the c-statistic compared with the core model with the bSS (from 0.69 to 0.70) and gave little incremental value in the standardized net benefit.

Conclusions

In elderly patients with ACS with multivessel disease undergoing PCI, incomplete revascularization was associated with worse outcome at 1-year follow-up. However, there was no clear incremental value of the rSS in the prediction of 1-year adverse outcome compared with a model including clinical variables and bSS.