DES Show Better Outcomes vs. BMS in Elderly, Though Use Declining

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Between 2004 and 2008, use of drug eluting stents (DES) decreased among older patients, particularly those aged 85 or older, according to a study published in the January 10, 2012, issue of the Journal of the American College of Cardiology. However, very old patients who did receive DES had lower rates of adverse events, including decreased mortality, compared with those who received bare-metal stents (BMS).

In an observational study, Tracy Y. Wang, MD, of the Duke Clinical Research Institute (Durham, NC), and colleagues reviewed data from 471,006 patients aged 65 years or older enrolled in the National Cardiovascular Data Registry CathPCI registry between 2004 and 2008, analyzing the use and comparative efficacy of DES vs. BMS. The cohort was divided into 3 age groups:

  • 65-74 years: 241,196 patients (51%)
  • 75-84 years: 187,656 (40%)
  • 85 or older: 42,154 (9%)

Generally, the oldest patients had higher rates of in-hospital mortality, and those undergoing acute PCI had higher rates of MI rehospitalization and bleeding but the lowest rate of repeat revascularization.

Stent Choices Run Counter to Outcome Data

Between 2005 and 2008, DES use significantly decreased across all age groups, but the steepest decline occurred among patients 85 years or older. The trend held true for both acute and elective PCI (P < 0.0001 for all comparisons).

Nonetheless, patients implanted with DES compared with BMS had lower mortality across all age groups, although the difference narrowed with increasing age (P for interaction < 0.001; table 1).

Table 1. Long-term (Median 641 Days) Mortality for DES vs. BMS, Stratified by Age

Age

DES

BMS

Adjusted HR

95% CI

85 Years

29%

38%

0.80

0.77-0.83

75-84 Years

17%

25%

0.77

0.75-0.79

65-74 Years

10%

16%

0.73

0.71-0.75


In addition, the risk for rehospitalization due to MI decreased with DES use compared with BMS use, although in this case the effect increased with age (P for interaction < 0.001; table 2).

Table 2. MI Rehospitalization for DES vs. BMS, Stratified by Age

Age

DES

BMS

Adjusted HR

95% CI

85 Years

9%

12%

0.77

0.71-0.83

75-84 Years

7%

9%

0.81

0.77-0.84

65-74 Years

7%

8%

0.84

0.80-0.88


On the other hand, use of DES conferred no advantage in regard to revascularization. Bleeding risk was also similar between DES and BMS groups across all age groups.

The Very Elderly Are Different

In a telephone interview with TCTMD, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said the trend toward lower use of DES in the oldest patients was not surprising.

“There are obvious reasons why clinicians would be more cautious about using DES in these elderly patients who have a greater risk for bleeding,” Dr. Kirtane said. “One is the increasing awareness of the risks of dual antiplatelet therapy. Another is the fact that we are generally continuing patients on [the therapy] longer than was originally indicated in approval studies.”

However, Dr. Kirtane observed that clinicians spend less time trying to maximize the potential benefit of DES and more time trying to ensure that patients are fully able to tolerate them.

Improved Outcomes Questionable

Although Dr. Wang and colleagues suggest that DES might confer a clinical benefit in the extremely elderly population compared with BMS, Dr. Kirtane questioned the validity of this conclusion.

“Do I believe that DES reduced mortality in elderly patients? No, I don’t,” Dr. Kirtane said. “I think that what we are seeing in this analysis, as in every other one that has looked at DES vs. BMS in an observational way, is residual confounding at play.”

Nonetheless, Morton J. Kern, MD, of the University of California Irvine (Irvine, CA), suggested the take-home message of this study is that many older people may be able to tolerate the use of DES. “What this tells us is that people should not be afraid to offer older individuals the best therapy that is available, which is now in most cases, DES,” he told TCTMD in a telephone interview.

Dr. Kirtane did not disagree, noting that clinicians should be reassured by the study about the decision to use DES in older, appropriately selected patients.

Study Details

As the age of patients increased, they were more likely to be white and female. In addition, older patients had a higher prevalence of heart failure and stroke, and a higher Charlson index score.

 


Source:
Wang TY, Masoudi FA, Messenger JC, et al. Percutaneous coronary intervention and drug-eluting stent use among patients ≥ 85 years of age in the United States. J Am Coll Cardiol. 2012;59:105-112.

 

 

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Disclosures
  • Dr. Wang reports research grants to the Duke Clinical Research Institute from multiple device and pharmaceutical companies and consulting fees or honoraria from AstraZeneca and Medco Health Solutions, Inc.
  • Dr. Kirtane reports no relevant conflicts of interest.
  • Dr. Kern reports consulting for St. Jude Medical and Volcano Therapeutics.

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