Percutaneous Coronary Intervention in Elderly Patients: Is It Beneficial?

Persons aged 65 years or older, often referred to as the elderly, are a rapidly increasing population in the United States. Cardiovascular disease is the most common cause of morbidity and death in this age group, and acute coronary syndrome accounts for a significant proportion of the deaths. Percutaneous coronary intervention is a well-established treatment for acute coronary syndrome and symptomatic coronary artery disease. However, community studies have shown that elderly patients are less likely to undergo revascularization, perhaps due to a "treatment-risk" paradox: elderly patients-at higher risk of morbidity and death from acute coronary syndrome-are denied revascularization even though they are likely to benefit from it. Age alone is one of the many reasons why percutaneous coronary intervention is avoided in elderly patients. This review examines past clinical trials and the existing evidence that supports performing percutaneous coronary intervention in elderly patients.     

Revascularization in Heart Failure: Coronary Bypass or Percutaneous Coronary Intervention?

Coronary artery disease (CAD) is the most common cause of heart failure in Western countries. Selected patients who have low left ventricular ejection fraction (LVEF) and CAD clearly benefit from coronary revascularization with coronary artery bypass grafting (CABG). CABG results seem to be superior to percutaneous coronary intervention (PCI) in the few comparative studies of the two approaches in patients who have CAD and low LVEF completed to date. Clinical improvement should be expected in most patients who undergo CABG. This is important for patients who have a limited life span that they could spend with a good functional status rather than being hospitalized for multiple repeat PCIs or symptomatic deterioration.     

Left Main Coronary Artery Disease in Diabetics: Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting?

The choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for myocardial revascularization in patients with left main disease (LMD) is controversial. There is general agreement that CABG is appropriate for all patients, and PCI is acceptable for those with low-to-intermediate anatomic complexity. However, there is uncertainty about the relative safety and efficacy of PCI in patients with more complex LMD and with comorbidities such as diabetes. No direct comparison trial has focused on revascularization in diabetic patients with LMD, and thus conclusions on the topic are subject to the limitations of subgroup analysis, as well as the heterogeneous exclusion criteria, and methodologies of individual trials. The available evidence suggests that among diabetics, CABG is superior in patients with LMD with SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and dardiac surgery) score greater than 33, distal bifurcation disease, or multivessel disease. PCI may be appropriate in those with less-extensive disease or those with limited life expectancy or high surgical risk.     

Does Proximal Location of Culprit Lesion Confer Worse Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction?

ST segment elevation myocardial infarction (STEMI) from proximally located culprit lesion is associated with greater myocardium at jeopardy. In STEMI patients treated with thrombolytics, proximal culprit lesions are known to have worse prognosis. This relation has not been studied in patients undergoing primary percutaneous coronary intervention (PCI). In 3,535 STEMI patients with native coronary artery occlusion pooled from the primary angioplasty in myocardial infarction database, we compared in-hospital and 1-year outcomes between those with proximal (n = 1,606) versus non-proximal (n = 1,929) culprit lesions. Patients with proximal culprits were more likely to die and suffer major adverse cardiovascular events (MACE) during the index hospital stay (3.8% vs 2.2%, P = 0.006; 8.2% vs 5.8%, P = 0.0066, respectively) as well as during 1-year follow-up (6.9% vs 4.5%, P = 0.0013; 22% vs 17%, P = 0.003, respectively) compared to those with non-proximal culprits. After adjustment for baseline differences, proximal culprit was independently predictive of in-hospital death (adjusted odds ratio% 1.58, 95% confidence intervals, CI 1.05-2.40) and MACE (OR 1.41, CI 1.06-1.86), but not 1-year death or MACE. In addition, proximal culprit was independently associated with higher incidence of ventricular arrhythmias and sustained hypotension during the index hospitalization. The univariate impact of proximal culprit lesion on in-hospital death and MACE was comparable to other adverse angiographic characteristics, such as multivessel disease and poor initial thrombolysis in myocardial infarction flow, and greater than that of anterior wall STEMI. In conclusion, proximal location of the culprit lesion is a strong independent predictor of worse in-hospital outcomes in patients with STEMI undergoing primary PCI.     

Outcomes of Percutaneous Coronary Intervention in the Very Elderly：One-center Experience in a Chinese Patient Group

Objective To investigate the clinical and perioperative characteristics of patients ≥ 75 who undergoing percutaneous coronary intervention (PCI) and to evaluate the risk factors related to short-term post-PCI mortality in this specific patients group. Methods 1,035 consecutive subjects who underwent PCI from December 2011 to November 2013 were divided into four categories: (1) patients with stable angina (SA) ≥ 75 years (n = 58); (2) patients with SA < 75 years (n = 218); (3) patients with acute coronary syndrome (ACS) ≥ 75 years (n = 155); (4) patients with ACS < 75 years (n = 604). A multivariable logistic regression analysis was conducted to detect risk factors of six-month mortality in patients ≥ 75 years who had undergone PCI. Clinical comorbidities, in-hospital biochemical indicators, perioperative data, in-hospital and six-month outcomes were analyzed and compared among the four groups. Results Compared with the younger group, pa?tients ≥ 75 years were more likely to have hypertension, history of stroke, chronic obstructive pulmonary disease, peripheral vascular disease, cardiogenic shock and malignant arrhythmia, and they were admitted to hospital with relative lower weight, hemoglobin, albumin, trigly?ceride, higher creatinine, uric acid, urea nitrogen and pro-BNP. Left main artery lesions, multi-vessel, calcified lesions, chronic totally occlusion were also more likely to be seen in the elderly group. Univariate analysis revealed that age ≥ 85 years, cardiogenic shock or severe arrhythmia at admission, emergency PCI, prior stroke and chronic kidney disease were related to six-month mortality in elderly patients ≥ 75 years who underwent PCI. Multivariable logistic regression showed that cardiogenic shock or severe arrhythmia at admission, chronic kidney disease and prior stroke were independent risk factors predicting six-month mortality in elderly patients ≥ 75 years who had undergone PCI. Conclusions Our data showed that, compared with patients under 75 years, elderly patients (≥ 75 years) who had undergone PCI had a relative higher risk of mortality, and more often accompanied with multi-comorbidities, severer admission conditions and complex coronary lesions. Better eva?luation of risk factors and more intensively care should be taken to patients ≥ 75 years who had undergone PCI therapy to reduce complications.     

Impact of Chronic Thrombocytopenia on In-Hospital Outcomes After Percutaneous Coronary Intervention

Objectives

This study sought to evaluate the impact of chronic thrombocytopenia (cTCP) on clinical outcomes after percutaneous coronary intervention (PCI).

Does Occlusion Duration Influence Procedural and Clinical Outcome of Patients Who Underwent Percutaneous Coronary Intervention for Chronic Total Occlusion?

Background: Previous studies have reported that the indeterminable aging and long‐duration occlusion are associated with procedural failure and adverse long‐term outcome. We aimed to investigate the clinical impact of occlusion duration in a consecutive series of patients who underwent percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. Methods and Results: From October 2005 to June 2009, a total of 303 patients with 328 CTO lesions were consecutively treated achieving a success rate of 86.3%. The average of occlusion duration estimated in 62.5% of cases (known occlusion duration [KOD] patients, n = 188) was 29.8 ± 41.3 months. In the remaining 37.5% of cases, the occlusion duration was indeterminate (indetermination of occlusion duration [IOD] patients, n = 115). No influence of duration in procedural outcome was observed. Moreover, no differences of 1‐year major adverse cardiac events (MACE) were observed between KOD and IOD patients. The multivariate COX regression analysis identified diabetes mellitus and multivessel coronary disease as independent predictors of 12‐month MACE (HR 5.023; 95% CI 0.164–9.653; P = 0.025 and HR 0.801; 95% CI 0.109–0.909, P = 0.033). The analysis did not show any influence of IOD and long occlusion duration in the occurrence of MACE. Predictors of angiographic failure recognized with multivariate binary logistic were vessel diameter <2.5 mm (OR 5.3; 95% CI 1.19–8.91; P = 0.02), CTO length >20 mm (OR 6.3; 95% CI 1.22–9.54; P = 0.02), and severe calcification (OR 3.2; 95% CI 1.62–5.51; P = 0.03). Conclusion: IOD and long duration of CTO do not affect procedural and clinical outcome of patients who underwent CTO PCI. This marks the importance of considering PCI treatment, a reliable strategy in cases of IOD or long occlusion duration. (J Interven Cardiol 2011;24:223–231)