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Percutaneous coronary interventions in very elderly patients referred due to symptomatic coronary disease

Jonathan Miara, Adolfo Ferrero Guadagnoli, Alejandro E Contreras, Miguel A Ballarino, Carlos R Leonardi, Marcos Amuchástegui

Revista Argentina de Cardioangiología Intervencionista 2021;(4): 0218-0222 | Doi: 10.30567/RACI/20214/0218-0222


The elderly population is increasing and has a high cardiovascular risk. This population has been systematically excluded from the clinical trials to the point that the evidence on what the best treatment is remains unknow to this date. We analyzed data from 63 consecutive patients > 85 years treated with percutaneous coronary intervention to assess the results of patients who were offered percutaneous treatment for the management of their symptomatic coronary artery disease. They were categorized into 3 clinical groups (unstable angina, NSTEMI or STEMI) and follow-up was divided into 2 groups (hospitalization after 1 month or after 1 year). The patients’ mean age was 87.54 years (85 to 99), 66.7% were women, and 33.3% were men. A total of 33.3% presented with STEMI, 38% with NSTEMI, and 28.7% with unstable angina.
On average, a total of 1.29 PCIs were performed (a minimum of 1 and a maximum of 4) and 1.21 stents being implanted (a minimum of 0 and a maximum of 3). Radial access was used in 36% of the patients.
Procedural complications were AKI (24%). A total of 2% of the patients required dialysis, 12% had major bleeding, and 5% perioperative AMI. No strokes were reported. The overall in-hospital cardiovascular mortality rate was 17% at the 1-month follow-up (being 5%, 13%, and 33% respectively for unstable angina, NSTEMI or STEMI, respectively), and 20% at 1 year. The mean hospital stay was 5.44 days (a minimum of 0 days and a maximum of 41 days).


Palabras clave: coronary interventions, angioplasty, elderly patients, risk.

La población anciana está en progresivo aumento y presenta un elevado riesgo cardiovascular. El mejor tratamiento para ofrecerles no se conoce precisamente ya que esta población ha sido sistemáticamente excluida de los estudios clínicos. Con el objetivo de evaluar los resultados que obtuvieron nuestros pacientes ancianos a los cuales se les ofreció tratamiento percutáneo de su patología coronaria sintomática, analizamos los datos de 63 pacientes consecutivos > 85 años que fueron sometidos a intervención coronaria percutánea. Se dividieron en 3 grupos clínicos (angor inestable, infarto agudo c/ST o Infarto agudo s/ST) y el seguimiento en 2 grupos (hospitalización hasta el mes posterior, y al año). La edad promedio de los pacientes fue 87,54 (rango: 85-99), 66,7% mujeres y 33,3% hombres. El 33.3% se presentó con infarto agudo c/ST, el 38% con infarto agudo s/ST y el 28,7% con angina inestable.
Se realizaron en promedio 1,29 (1-4) PCI, con 1,21 (0-3) stents. El acceso fue radial en el 36%.
Las complicaciones relacionadas con el procedimiento fueron: 24% IRA o reagudización de una falla preexistente y el 2% requirió diálisis, 12% de sangrado mayor, 5% de IAM periprocedimiento. No hubo accidentes cerebrovasculares. La mortalidad cardiovascular global fue de 17% durante la internación y al mes (con 5%, 13%, y 33%, respectivamente, para angor inestable, infarto agudo s/ST o infarto agudo c/ST) y del 20% al año. La internación promedio fue de 5,44 (0-41) días.


Keywords: intervenciones coronarias, angioplastia, pacientes ancianos, riesgo.


Los autores declaran no poseer conflictos de intereses.

Fuente de información Colegio Argentino de Cardioangiólogos Intervencionistas. Para solicitudes de reimpresión a Revista Argentina de Cardioangiología intervencionista hacer click aquí.

Recibido 2021-06-04 | Aceptado 2021-09-13 | Publicado


Licencia Creative Commons
Esta obra está bajo una Licencia Creative Commons Atribución-NoComercial-SinDerivar 4.0 Internacional.

Figura 1. Chart showing both the general and the study population.

Figura 2. Chart with the procedural complications.

Tabla 1. General characteristics of the population.

Tabla 2. Intervención coronaria percutánea.

INTRODUCTION

Life expectancy has been increasing parallel to the growth of the elderly population. According to the Census of 2010, the rate of people > 65 in Argentina was 10.2% compared to 7%1 back in 1970. Old age per se is one of the greatest cardiovascular risk factors, and coronary artery disease is the most common cause of death among the elderly.2 In this context, it is of paramount importance to implement effective treatments specifically aimed at elderly patients with coronary artery disease. However, little is known about the management and results of the treatment of coronary artery disease in this age group since these patients have systematically been excluded from clinical trials.3

This population poses a double challenge. On the one hand, they are a high-risk group to undergo percutaneous coronary interventions4 since this population has a high-risk profile due to the associated comorbidities, physical frailty, polymedication, high ischemic load due to multivessel coronary artery disease, and severe coronary artery calcification. On the other hand, they can also benefit from a percutaneous coronary intervention, which means that the risk-benefit ratio should be carefully taken into consideration.

The objective of this study of “very elderly” patients (> 85 years) is to assess the results of coronary angioplasty in our hospital in the subgroup of patients we call very elderly.

MATERIALS AND METHODS

Retrospective, observational, and descriptive study including data from our hospital coronary care unit database and the patients’ health records. Data from consecutive patients treated with coronary angioplasty who were > 85 years whenthe procedure was performed were extracted. The patients selected were subcategorized based on their clinical presentation into: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation acute myocardial infarction (NSTEMI), and unstable angina (UA).

Patients were diagnosed with STEMI, NSTEMI based on the third universal definition of myocardial infarction of 2012.6 The group of patients with UA included “outpatients” with early-onset (< 0 = to 2 months) or late-onset angina (< 0 = to 2 months) despite the use of, at least, 2 antianginal agents who may or may not have ischemia provable in a non-invasive positive test like stress echocardiography or myocardial perfusion scintigraphy.

Decisions on the procedure, access site, use of adjuvant drug therapy, and type of stent were left to the operator’s criterion. Only the index events of patients treated with staged procedures were included. These patients received another elective percutaneous coronary intervention (PCI) after the culprit vessel was previously treated.

All patients treated with PCI received heparin at a dose of 80 mg/kg, aspirin, ticlopidine or clopidogrel according to the standard effective regulations. Patients treated with drug-eluting stents received a 1-year minimum course of dual antiplatelet therapy.

Follow-up was divided into 2 different in-hospital disease progression follow-ups: 1) until the 30-day follow-up; 2) until the 1-year follow-up. Follow-up took place at the doctor’s office of at the treating center. Also, through phone calls with those who underwent followed-up in a different center. All patients were informed and trained on the standard therapy of secondary prevention at discharge according to the recommendations applicable to this date.

Angioplasty-related adverse events at the follow-up were in-hospital mortality (defined as the appearance of death during the hospital stay after the procedure, after 30 days, and after 1-year). Cardiac death was defined as death due to arrhythmias, mechanical complications (myocardial ruptures or severe valvular compromise) or refractory heart failure. The remaining causes were defined as non-cardiogenic.

Reinfarction after acute myocardial infarction (R-AMI) is defined as the presence of, at least, 2 of the 3 following criteria: changes on the ECG, precordial pain (or other anginal equivalent) or elevated biomarker levels after the PCI.

Stroke was defined as the permanent loss of neurological function (including coma) following an ischemic or hemorrhagic vascular event as seen on the brain images obtained through computed tomography or magnetic resonance imaging.

Postoperative acute kidney injury (AKI) was defined as oliguria (production of urine < 30 mL/h) or anuria and was associated with a daily increase of serum creatinine and blood urea nitrogen of 0.1 mg/dL and 0.10 mg/dL, respectively or with the need for hemodialysis or peritoneal dialysis sometime after the coronary intervention and up to 10 days later.

Patients were considered smokers following current or past smoking habits. The number of cigarettes smoked was disregarded to this point.

Hypertensive patients (HTP) were patients with a past medical history of systemic arterial hypertension or medicated against such condition. Patients with pressure levels > 140 mmHg.

Dyslipidemic patients (DLP) were those with a past medical history of hypertriglyceridemia, hypercholesterolemia or both. The ab results were: triglycerides > 150 mg/dL and cholesterol > 200 mg/dL.

Diabetic patients (DBP) were those with a past medical history of diabetes or treated with insulin or with some hypoglycemic agent.

Major bleeding was defined as the need for transfusion of, at least, 2 red blood cell units after the procedure.

The statistical analysis was performed using the statistical system Infostat (Universidad Nacional de Córdoba, 2014, free version). The categorical variables were expressed as percentage, and the continuous ones as mean and interquartile range.

RESULTS

From January 1994 through June 2019 our center performed coronary angioplasties to 540 patients. A total of 63 of these patients were > 85 (figure 1) with a mean age of 87.54 (85 to 99), 66.7% were women while 33.3% were men. A total of 33.3% presented with STEMI (anterior, 57%; inferior, 29%; lateral, 14 %), 38% with NSTEMI, and the remaining 28.7% were referred due to UA.

Regarding the cardiovascular risk factors (table 1) known at the time the PCI was performed, it was confirmed that 84% of the patients were HTP, 54% were DLP, 35% were past or present smokers, 12% had chronic obstructive pulmonary disease, 29% were DBP (and 6% of these were insulin-dependent patients). A total of 29% of the patients had had a previous acute myocardial infarction (AMI), 17% of the patients a previous PCI, and 10% of the patients had been treated with surgical revascularization (coronary artery bypass graft).

A total of 54% of the patients were in normal sinus rhythm, 12% had atrial fibrillation, and 10% were pacemaker carriers and had rhythms associated with such pacemakers. A total of 5% of these patients had complete right bundle brunch block (RBBB), and 13% complete left bundle brunch block (LBBB).

According to the coronary angiography, 10% had significant left main coronary artery disease, 52% left anterior descending coronary artery disease, 40% right coronary artery disease, and 30% left circumflex artery disease. On average, the number of vessels that were significantly compromised (≥ 70% obstruction) was 1.89 (1.00 to 3.00), the mean number of PCIs performed was 1.29 (1 to 4), the average number of stents used was 1.21 (0 to 3) of which 22% were drug-eluting stents and the remaining ones, bare-metal stents. The access route was radial in 36% of the cases (table 2).

Regarding procedural complications (figure 2) we should mention that no complications were reported intraoperatively. Also, during the hospital stay, 24% of the patients developed AKI or preexisting failure relapse, and 2% required dialysis. A total of 12% of the patients had major bleeding, and 5% a perioperative AMI. No periprocedural ischemic or hemorrhagic strokes were reported.

The overall cardiovascular mortality rate was 17% during the hospital stay and at the 1-month follow-up (5%, 13%, and 33%, respectively if the clinical presentation is considered whether UA, NSTEMI or STEMI), and 20% at the 1-year follow-up.

The mean hospital stay was 5.44 days (0 to 41).

DISCUSSION

In the routine clinical practice, the elderly patients are often prescribed with medical or conservative therapy instead of a PCI.7 This is, in part, due to the fact that these patients are very challenging because they can have atypical clinical presentations and even late-onset clinical manifestations, more chances of having concomitant diseases, cognitive impairment, physical frailty, polymedication, and a more complex coronary artery disease (multiple vessels, tortuosity, and significant calcification), and even a greater ischemic load.8 Many times it is believed that these challenges minimize benefits and increase the risk of complications associated with invasive treatment. Consequently, traditionally the management of very old patients has been more conservative compared to what the clinical practice guidelines actually recommend with suboptimal access to angiography, early revascularizations, and even optimal medical therapy.9 However, there is strong evidence nowadays that high-risk patients benefit from PCI, which should bring the threshold down when it comes to the implementation of more aggressive strategies in this age group of unquestionable high risk.10

Currently, primary PCI performed within the recommended time frames is the therapy of choice for patients with STEMI. Therefore, thrombolytic agents are spared for situations in which mechanical reperfusion is not available. Very elderly patients with STEMI treated with PCI have lower morbidity and mortality rates compared to those treated with medical therapy or thrombolytic agents.11 Regarding the specific comparison with fibrinolytic agents we have evidence in favor of the PCI regarding mortality, morbidity, and safety coming from randomized clinical trials that compared these strategies in very elderly patients.12,13 Also, a meta-analysis of 22 randomized trials that compared the PCI vs fibrinolytic therapy and analyzed 410 octogenarian patients confirmed lower mortality rates favorable to the PCI (18.3 vs 26.4; P = .04).14 In our series, the in-hospital mortality rate of patients with STEMI was 33%. This mortality rate is similar to the one reported by other studies that included octogenarian and nonagenarian patients (mean age, 88 years) like we did.15 Complications occurred in 20% of the patients. Procedural complications were major bleeding (2%), perioperative AMI (10%), and AKI (33%).

In the case of very elderly patients with NSTEMI the situation is similar in the sense that these patients receive suboptimal medical therapy compared to the current recommendations.15 However, this subgroup of patients benefits in terms of mortality, especially, morbidity when treated with percutaneous revascularization and even more when this therapy is complemented with the optimal medical therapy.16 The CRUSADE trial confirmed a lower in-hospital mortality rate in elderly patients similar to ours treated with this invasive strategy.17 Another recent study based on data from the Nationwide Inpatient Sample proved that, compared to an early conservative approach, an early invasive strategy in octogenarian patients with NSTEMI was associated with a lower in-hospital mortality rate, fewer acute ischemic strokes, intracranial hemorrhages, GI bleeding, and even shorter hospital stays.18 In our own experience, elderly patients with this syndrome had a 13% mortality rate during the hospital stay with a 6% rate of overall complications (major bleeding, 8%, and AKI, 17%).

The European Society of Cardiology, the American College of Cardiology, and the American Heart Association recommend treating very old patients individually with a correct balance regarding the risk-benefit ratio. They also recommend taking into consideration ischemia, the risk of bleeding, life expectancy, and comorbidities including cognitive function, quality of life, and the patient’s wishes before deciding on the most appropriate therapy.19,20,21

In the subgroup of patients treated with elective PCIs due to UA, the rate of complications was low (6%) (being chronic kidney disease, 22%, and major bleeding, 16% the most common complications of all). Also, only 1 patient died of retroperitoneal bleeding, meaning that this death was directly associated with the procedure. Studies comparing the invasive vs the conservative strategy in these patients conclude that anginal symptoms, and quality of life22 do actually improve. Also, that there is a greater absolute reduction of the mortality rate.23

Regarding the stent that should be used to treat the coronary lesions of elderly patients we can say that, as it happens with the other patients, the benefit of using drug-eluting stents is a lower rate of target vessel revascularization and fewer acute myocardial infarctions at the follow-up. However, there does not seem to be a significant impact regarding mortality and strokes.24

We should mention the prevention of complications in these patients since these complications have an impact on survival. With this goal in mind, over the last 5 years, we have been using the radial approach in all our patients (except when this approach was unavailable). This approach reduced access site bleeding significantly to the point that patients treated with this technique never had major bleeding.

Our study limitations are those of an observational and retrospective study. That means that the possibility of selection bias, as well as the possibility that confounding factors never actually went away still stands. However, we believe that due to the lack of data from large randomized clinical trials, observational studies like ours are relevant because they provide us with valuable evidence.

CONCLUSION

The acute coronary syndrome in the elderly population is a serious complication. However, it can be treated invasively with some acceptable risks. We believe chronological age should not be the main determining factor in the decision to use invasive treatment.

What does this study add?

# The growing number of elderly patients due to the increased life expectancy is associated with more of these patients ending up in cath labs to solve their acute coronary syndromes.

# Due to their age, frailty, and common comorbidities these are high-risk patients to undergo percutaneous coronary interventions.

# In our study we could confirm, and it is actually our biggest feat, the safety and effectiveness of the procedures performed in this age group.

# Currently, as far as we know, no national experiences have been published specifically addressing that group of patients we call the elderly.

References

  1. Censos Nacionales de Población, Familias y Viviendas 1970. Censo Nacional de Población y Viviendas 1980 y 1991. Censo Nacional de Población, Hogares y Viviendas 2001 y 2010. En: Http://www.indec.gob.ar/censos_total_pais.asp?id_tema_1=2&id_tema_2=41&id_tema_3=135&t=0&s=0&c=2010. Consultado 01/09/2016.

  2. Kung HC, Hoyert DL, Xu J, et al. Division of vital statistics. deaths: final data for 2005. National vital statistics reports. Natl Vital Stat Rep 2008;56:1-120.

  3. Alexander KP, Newby LK, Armstrong PW, et al. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: A scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: In collaboration with the Society of Geriatric Cardiology. Circulation 2007;115:2570-89.

  4. Wang TY, Gutierrez A, Peterson ED. Percutaneous coronary intervention in the elderly. Nature reviews. Cardiology 2011;8:79-90.

  5. Johnman C, Oldroyd KG, Mackay DF, et al. Percutaneous Coronary Intervention in the Elderly Changes in Case-Mix and Periprocedural Outcomes in 31758 Patients Treated Between 2000 and 2007. Circ Cardiovasc Interv 2010;3:341-5.

  6. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, Hite HD. Third universal definition of myocardial infarction. Nat Rev Cardiol 2012;9:620-33.

  7. Hoyoun Won, Ae-Young Her, Byeong-Keuk Kim, et al. Percutaneous Coronary Intervention Is More Beneficial Than Optimal Medical Therapy in Elderly Patients with Angina Pectoris. Yonsei Med J 2016:57(2):382-7.

  8. Jaguszewski M, Ghadri JR, Diekmann J, et al. Acute coronary syndromes in octogenarians referred for invasive evaluation: treatment profile and outcomes. Clin Res Cardiol 2015;104:51-8.

  9. Bagnall AJ, Goodman SG, Fox KA, et al. Influence of age on use of cardiac catheterization and associated outcomes in patients with non-ST-elevation acute coronary syndromes. Am J Cardiol 2009;103:1530-36.

  10. Rittger H, Hochadel M, Behrens S, et al. Age-related differences in diagnosis, treatment and outcome of acute coronary syndromes: results from the German ALKK Registry. EuroIntervention 2012;7:1197-205.

  11. Dangas GD, Singh HS. Primary percutaneous coronary intervention in octogenarians: navigate with caution. Heart 2010;96:813-4.

  12. de Boer MJ, Ottervanger JP, van ‘t Hof AW, Hoorntje JC, Suryapranata H, Zijlstra F. Reperfusion therapy in elderly patients with acute myocardial infarction: A randomized comparison of primary angioplasty and thrombolytic therapy. J Am Coll Cardiol 2002;39:1723-8.

  13. Goldenberg I, Matetzky S, Halkin A, et al. Primary angioplasty with routine stenting compared with thrombolytic therapy in elderly patients with acute myocardial infarction. Am Heart J 2003;145:862-7.

  14. de Boer SP, Barnes EH, Westerhout CM, et al. High–risk patietns with ST–elevation myocardial infarction device greatest absolute benefit from primary percutaneous coronary intervention:results from the primary coronary angioplasty trialist versus thrombolysis (PCAT)-2 collaboration. Am Heart J 2011;161:500-7.

  15. Antonsen L, Okkels Jensen L, Juhl Terkelsen C, et al. Outcomes After Primary Percutaneous Coronary Intervention in Octogenarians and Nonagenarians With ST-Segment Elevation Myocardial Infarction: From the Western Denmark Heart Registry. Catheter Cardiovasc Interv 2013;81:912-9.

  16. Shanmugam VB, Harper R, Meredith I, Malaiapan Y, Psaltis PJ. An overview of PCI in the very elderly. Geriatr Cardiol 2015;12:174-84.

  17. Skolnick AH, Alexander KP, Chen AY, et al. Characteristics, management, and outcomes of 5,557 patients age greater than or equal to 90 years with acute coronary syndromes: Results from the CRUSADE Initiative. J Am Coll Cardiol 2007;49:1790-7.

  18. Kolte D, Khera S, Palaniswamy C, et al. Early Invasive Versus Initial Conservative Treatment Strategies in Octogenarians with UA/NSTEMI. Am J Med 2013;126:1076-83.

  19. Kolh P, Windecker S, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014;35(37):2541-619.

  20. Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999-3054.

  21. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):2645-87.

  22. Pfisterer M, Bertel O, Erne P, et al. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (time): A randomised trial. Lancet 2001;358:951-7.

  23. Singh M, Peterson ED, Roe MT, et al. Trends in the association between age and in-hospital mortality after percutaneous coronary intervention: National cardiovascular data registry experience. Circulation 2009;2:20-6.

  24. De Belder A, De la Torre Hernandez JM, Lopez-Palop R, et al. The XIMA Trial (Xienceor Vision Stents for the Management of Angina in the Elderly). A Prospective Randomized Trial of Everolimus-Eluting Stents Versus Bare-Metal Stents in Octogenarians. J Am Coll Cardiol 2014;63(14):1371-5.

Autores

Jonathan Miara
Servicio de Cardioangiología Intervencionista, Hospital Privado Universitario de Córdoba. Servicio de Cardioangiología Intervencionista, Sanatorio Privado Mayo SA, Córdoba..
Adolfo Ferrero Guadagnoli
Servicio de Cardioangiología Intervencionista, Hospital Privado Universitario de Córdoba..
Alejandro E Contreras
Servicio de Cardiología, Hospital Privado Universitario de Córdoba.
Miguel A Ballarino
Servicio de Cardioangiología Intervencionista, Hospital Privado Universitario de Córdoba..
Carlos R Leonardi
Servicio de Cardioangiología Intervencionista, Hospital Privado Universitario de Córdoba..
Marcos Amuchástegui
Servicio de Cardioangiología Intervencionista, Hospital Privado Universitario de Córdoba. Servicio de Cardiología, Hospital Privado Universitario de Córdoba.

Autor correspondencia

Jonathan Miara
Servicio de Cardioangiología Intervencionista, Hospital Privado Universitario de Córdoba. Servicio de Cardioangiología Intervencionista, Sanatorio Privado Mayo SA, Córdoba..

Correo electrónico: jonymiara@gmail.com

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Revista Argentina de Cardioangiología intervencionista
Issue # 4 | Volumen 11 | Año 2021

Etiquetas

coronary interventions, angioplasty, elderly patients, risk

Tags

intervenciones coronarias, angioplastia, pacientes ancianos, riesgo

Titulo
Percutaneous coronary interventions in very elderly patients referred due to symptomatic coronary disease

Autores
Jonathan Miara, Adolfo Ferrero Guadagnoli, Alejandro E Contreras, Miguel A Ballarino, Carlos R Leonardi, Marcos Amuchástegui

Publicación
Revista Argentina de Cardioangiología intervencionista

Editor
Colegio Argentino de Cardioangiólogos Intervencionistas

Fecha de publicación
2021-11-01

Registro de propiedad intelectual
© Colegio Argentino de Cardioangiólogos Intervencionistas

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