Advanced Age Shouldn’t Be a Barrier to PCI, Study Suggests
Very elderly patients have typically been excluded from the major trials. This latest study fills a gap, although larger data sets are needed.
A patient’s age alone should not deter physicians from using PCI, according to new registry data. Although all-cause mortality was higher in patients 80 years or older than in those aged 75 to 80, there were no statistically significant differences in rates of cardiac death, MI, cerebrovascular accident, or its composite.
These endpoints as well as repeat intervention and stent thrombosis were at an “acceptable” level, say Robert Gerber, PhD (Conquest Hospital, East Sussex, England), and colleagues.
“This is a ‘real-world’ type study, and we demonstrate that elderly patients should not be prejudiced against, as the cause for ischemic events is more related to comorbidity and independent of age,” Gerber told TCTMD in an email. “In fact, the logistic regression demonstrated that bleeding was the only predictor of events and that this again was independent of age.”
Gregory Roth, MD, MPH (University of Washington Institute of Health Metrics and Evaluation, Seattle), who did not take part in the study, told TCTMD that it fills in a knowledge gap.
“In general, in medicine we have done a bad job of studying people in this oldest age group,” he said. “We know the population in general is aging quite rapidly. And so increasingly it is important for us to collect outcomes data and study the effect of our treatment and intervention on the oldest older people, above the age of 85 or 90.”
Yet while the analysis by Gerber et al addresses an important question, Roth said the findings aren’t enough to affect the way clinicians practice. “We still don’t know whether PCI provides the same benefits for those who are very old, in this case above the age of 85 or 90, than for those who are slight younger in their early 80s,” he commented. “I don’t think that this paper answers the question that investigators proposed [ie, whether there were true disparities based on age] because I think it was underpowered to show any significant differences.”
Elderly Patients May Safely Receive PCI
For their paper published online July 2, 2017, in the Journal of Interventional Cardiology, Gerber and his co-investigators followed 580 patients for a mean period of 30.8 months. Participants were divided into two groups, 253 very elderly patients (older than 80 years) and 327 elderly patients (75-80 years old), who were receiving PCI between April 2006 and November 2011 at East Sussex NHS Trust. Nearly six in 10 presented with ACS.
In total, 624 lesions were identified and assessed. Patient demographics as well as baseline, procedural, and periprocedural characteristics were collected.
BMS were more commonly used in the elderly than in the very elderly, although DES use was similar in both groups (with a minority of patients in both groups not receiving a stent). These numbers suggest that PCI operators are confident in both groups’ abilities to follow their dual antiplatelet therapy regimen appropriately post-PCI, Gerber et al write.
All-cause mortality was significantly higher among the very elderly population compared with the elderly (11.9% vs 6.1%), but differences in cardiac mortality (6.3% vs 3.7%) and major adverse cardiac and cerebrovascular events (16.2% vs 12.5%) did not reach statistical significance. Incidence of MI was 4.7%, stroke 1.4%, definite/probable stent thrombosis 1.9%, and TIMI major bleeding 6.4%, with no statistically significant differences between the two groups.
Looking at the Big Picture
Although the differences between the populations seem small, Roth noted that there were higher rates of complications among those in the oldest group. Yet this “really isn’t surprising as these patients are often sicker and more frail,” he added.
Looking ahead at the question of how best to treat the very elderly, Roth suggested focusing on a larger population and working with other countries that have large PCI registries like Saudi Arabia and the United States. Moreover, he emphasized that it’s important to look at the big picture beyond PCI. “We want to know about the tradeoff between PCI and all of the other treatments that could go on for people with atherosclerotic vascular disease in these age groups,” Roth said. “So we really need a registry of coronary artery disease and all of its comorbidities, not just a procedure registry.”
Gerber told TCTMD that his research group now aims to “develop a frailty score, which can guide physicians into making appropriate decisions about suitability of PCI in the very elderly.” The RINCAL and SENIOR-RITA trials, he added, are also currently “examining medical management of ACS in the elderly versus timely PCI.”
For now, Gerber and his colleagues conclude: “Age alone in the absence of other noncardiac factors should not prohibit a patient from access to percutaneous coronary revascularization.”
Gerber RT, Arri SS, Mohamed MO, et al. Age is not a bar to PCI: Insights from the long-term outcomes from off-site PCI in a real-world setting. J Interven Cardiol. 2017;Epub ahead of print.
- Gerber and Roth report no relevant conflicts of interest.