Outcomes of Nonagenarians with Acute Myocardial Infarction with or without Coronary Intervention

Percutaneous coronary intervention (PCI) is the mainstay treatment of acute myocardial infarction (AMI); however, many clinicians are reluctant to perform PCI in the elderly population. This study aimed to compare the clinical outcomes of PCI versus medical therapy in nonagenarian Korean patients with AMI. We compared the clinical outcomes of nonagenarian patients with AMI with or without PCI. From the pooled data, based on a series of Korean AMI registries during 2005−2020, 467 consecutive patients were selected and categorized into two groups: the PCI and no-PCI groups. The primary endpoint was 1-year major adverse cardiac event (MACE), a composite of all-cause death, non-fatal myocardial infarction, and any revascularization. Among the 467 participants, 68.5% received PCI. The PCI group had lower proportions of Killip classes III-IV, previous heart failure, and left ventricular ejection fraction <40%, but had higher proportions of all prescribed medications and STEMI diagnosis. The 1-year MACE and all-cause death were higher in the no-PCI group, although partially attenuated post-IPTW. Our study showed that nonagenarian patients with AMI undergoing PCI had better clinical outcomes than those without PCI. Nonetheless, further investigation is needed in the future to elucidate whether PCI is beneficial for this population.

[Interests and limitations of percutaneous coronary intervention strategy in nonagenarian patients: A single center experience]

AIM

To expose our center results in the angioplasty in nonagenarians and to evaluate its effectiveness but also the MACEs and the mortality in the short and long term.

METHODS

A retrospective study of 98 patients admitted to the Antibes hospital center from November 2013 to September 2018.

RESULTS

The median age was 91.8 [90.8-93.4]. 52.6% was male. 9.7% of the patients had a polyvascular site. 50.6% of patients had moderate renal failure. The radial approach was used in 88.4% of cases. 21.6% of patients had tri-truncal lesions, while 46.4% were monotruncular, LAD artery was the culprit artery in 67% of cases. One stent per lesion was used in the majority of cases. Our successful rate was 90%. After angioplasty, 96% of the patients underwent double antiaggregation platelet therapy, 74.4% under clopidogrel. The presence of arrhythmias before angioplasty, the femoral approach, the coronary dissection and cardiogenic shock after angioplasty were predictors of short- and long-term mortality. Diabetes, history of myocardial infarction, impaired left ventricular ejection fraction, calcified coronary lesions, occurrence of arrhythmias or signs of heart failure on post-procedure were predictors of MACE occurrence.

CONCLUSIONS

This study demonstrates that angioplasty in selected population of nonagenarians is perfectly feasible with a good risk/benefit ratio and specifies the different predictors of MACE, both short- and long-term mortality.

Drug-Eluting Versus Bare-Metal Stents in Older Patients: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Despite the high prevalence of ischemic heart disease in older patients, there is a substantial lack of evidence to guide clinical decision-making in this population. Hence, we performed a meta-analysis to determine the safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus bare-metal stents (BMS).

METHODS

Electronic databases were searched for randomized trials comparing DES with BMS in patients ≥70 years-old. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included different ischemic and bleeding events. Subgroup analyses for dual-antiplatelet therapy (DAPT) duration were conducted.

RESULTS

We included 7 trials with a total of 5449 patients. The use of DES compared with BMS was associated with a significant reduction in MACE (odds ratio [OR]:0.76; 95% confidence interval [CI]:0.62-0.93; P = 0.007) with no increased risk of bleeding events (OR: 1.07; 95% CI: 0.89-1.27; P = 0.48). However, longer duration of DAPT (>6 months) for the DES group increased bleeding events (OR: 1.52; 95% CI: 1.05-2.20; P = 0.03). In contrast, shorter DAPT showed persistent efficacy in reducing MACE in DES-treated patients with no increased bleeding events (OR: 0.72; 95% CI: 0.60-0.87; P < 0.01 and OR: 1.01; 95% CI: 0.84-1.22; P = 0.89, respectively).

CONCLUSIONS

In older patients who had undergone PCI, DES showed superior efficacy in reducing MACE with no increased risk of bleeding compared with BMS. Persistent MACE reduction was evident with shorter DAPT durations in DES-treated patients.

SUMMARY

This meta-analysis of randomized clinical trials demonstrated that drug-eluting stents were associated with a significant reduction in major adverse cardiovascular events with no increased risk of bleeding compared with bare-metal stents. The risk of bleeding was high with longer dual antiplatelet therapy duration for patients who underwent DES placement. However, short duration of dual antiplatelet therapy substantially reduced major adverse cardiovascular events with no increased bleeding risk.

Clinical outcomes in nonagenarians undergoing a percutaneous coronary intervention: data from the ORPKI Polish National Registry 2014-2016

BACKGROUND

Despite an increase in the proportion of nonagenarians in demographic structure, there is still a paucity of data on the utilization and outcome of percutaneous coronary interventions (PCIs) in this population. Also, very old patients are under-represented in randomized clinical trials and their treatment is still an emerging challenge. Thus, we sought to compare patient profiles and periprocedural outcomes of PCI in nonagenarians and patients younger than 90 years.

PATIENTS AND METHODS

Data were based on the Polish National Registry of PCI (ORPKI). A total of 651 080 consecutive patients with stable angina (SA) (n=260 920) or acute coronary syndrome (ACS) (n=390 160) undergoing PCI with at least one stent implanted were included. Patients were stratified according to age (<90 and ≥90 years).

RESULTS

Of all included patients, 4413 (0.7%) were older than or equal to 90 years. A similar rate of periprocedural complications was observed in both groups. However, cardiac arrest during both angiography and PCI occurred more often in nonagenarians (0.21 vs. 0.83%; 0.42 vs. 1.07%, respectively, for both P=0.001). Similarly, periprocedural mortality was higher in patients older than or equal to 90 years (0.27 vs. 1.88%; P=0.001). There were no differences in periprocedural outcomes between groups in the SA setting. However, a higher rate of periprocedural cardiac arrest [1971 (0.51%) vs. 43 (1.15%); P=0.001] and mortality [1622 (0.42%) vs. 83 (2.2%); P=0.001] were observed in nonagenarians compared with younger counterparts admitted with ACS.

CONCLUSION

Nonagenarians undergoing PCI because of SA may have similar outcomes as patients younger than 90 years. In ACS presentation, they may have worse outcomes than younger counterparts.

Temporal Trends, Complications, and Predictors of Outcomes Among Nonagenarians Undergoing Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

OBJECTIVES

The aim of this study was to determine temporal trends, in-laboratory complications, mortality, and predictors of mortality among nonagenarians undergoing percutaneous coronary intervention (PCI).

BACKGROUND

Nonagenarians (patients 90 years of age or older) undergoing PCI are often underrepresented in clinical trials, and their management remains challenging and controversial.

METHODS

All veterans undergoing PCI with data recorded in the Veterans Affairs Clinical Assessment, Reporting, and Tracking program from 2005 to 2014 were evaluated. Temporal trends in the use of PCI, occurrence of in-laboratory complications, and 30-day and 1-year mortality were assessed. Using a frailty model, predictors of 30-day and 1-year mortality in nonagenarians were evaluated.

RESULTS

Among all veterans undergoing PCI (n = 67,148) between 2005 and 2014, 274 (0.4%) were nonagenarians. The proportion of nonagenarians increased from 0.25% in 2008 to 0.58% in 2014. Compared with younger patients, nonagenarians had a greater risk for acute cardiogenic shock post-procedure (0.73% vs. 0.12%; p = 0.04) and no reflow (2.9% vs. 1.0%; p = 0.02). Unadjusted (10.6% vs. 1.4%; p < 0.0001) and adjusted 30-day mortality (odds ratio: 2.14; 95% confidence interval [CI]: 1.42 to 3.22) and unadjusted (16.3% vs. 4.2%; p < 0.0001) and adjusted 1-year mortality (odds ratio: 1.82; 95% CI: 1.27 to 2.62) were higher among PCI patients who were nonagenarians. The National Cardiovascular Data Registry risk score was highly predictive of both 30-day (hazard ratio: 2.29; 95% CI: 1.86 to 2.82) and 1-year (hazard ratio: 1.43; 95% CI: 1.07 to 1.90) mortality among nonagenarians.

CONCLUSIONS

Nonagenarians were a small but growing population with worse 30-day and 1-year mortality. The National Cardiovascular Data Registry risk score was a strong predictor of mortality in these patients.

Outcome after Elective Percutaneous Coronary Intervention Depends on Age in Patients with Stable Coronary Artery Disease - An Analysis of Relative Survival in a Multicenter Cohort and an OCT Substudy

Background

Age is a strong predictor of survival in patients with coronary artery disease. In elder patients with increasing co-morbidities percutaneous coronary intervention (PCI) is associated with more complications and worse outcome. The calculation of relative survival rates adjusts for the “background” mortality in the general population by correcting for age and gender. We analyzed if elder patients after elective PCI have a worse relative survival compared to younger patient groups.

Methods

A total of 8,342 patients who underwent elective PCI at two high volume centers between 1998 and 2009 were analyzed.

Results

The survival of our patients after PCI (observed survival) was slightly lower compared to the general population (expected survival) resulting in a slightly decreasing relative survival curve. In a multivariate Cox regression model age amongst others was a strong predictor of survival. Stratifying patients according to their age the relative survival curves of younger patients (Quartile 1: <58 years; 2,046 patients), elder patients (Quartile 3: 66–73 years; 2,090 patients) and very old patients (Quartile 4: >73 years; 2,307 patients) were similar. The relative survival of mid-aged patients (Quartile 2: 58–65 years; 1,899 patients) was better than that of all other patient groups. The profile of cardiovascular risk factors differs between the various groups resulting in different composition and burden of coronary plaques in an optical coherence tomography sub-study.

Conclusion

Patients after elective PCI have a slightly worse long-term survival compared to the age- and sex-matched general population. This is also true for different groups of age except for mid-aged patients between 58 and 63 years. Elder patients between 66 and 73 years and above 73 years have a similar relative survival compared to younger patients below 58 years, and might therefore have similar benefit from elective PCI.

Percutaneous coronary intervention in nonagenarian: a meta-analysis of observational studies

BACKGROUND

Developed countries are facing a sustained increase in life expectancy. Along with all social and cultural implications of increase lifespan, very elderly patients are undergoing percutaneous coronary intervention (PCI) with increasing frequency. However, there is limited evidence to guide clinicians in evaluating pros and cons of PCI in this very frail patient population. We, thus, aimed to perform a systematic review and meta-analysis of clinical studies reporting on PCI with stenting in nonagenarians.

METHODS

Studies reporting on five or more nonagenarians undergoing PCI were systematically searched in PubMed (last updated on November 2011). Baseline and clinical characteristics, in-hospital and long-term outcomes were systematically appraised. End points of interest were in-hospital and long-term follow-up incidence of death and Major Adverse Cardiac Events (MACE; i.e. the composite of death from all causes, myocardial infarction or repeat revascularization). Events were pooled with a random-effect model, generating summary estimates of incidence rates [95% confidence intervals (CI)].

RESULTS

A total of 10 studies were included, reporting on a total of 575 nonagenarians undergoing PCI with stenting who represented 1.99% (1.34-2.5) of those undergoing revascularization in the cath lab in a mean period of 5 (3-7) years. Twenty-three percent (13-45) of patients presented with STEMI (ST Segment Elevation Myocardial Infarction), 10% (7-12) with cardiogenic shock and in 78% (64-88) of cases a multivessel disease was diagnosed. Meta-analytic pooling of event rates showed an in-hospital death risk of 12.61% (9.71-15.50) with MACE in 16.41% (13.36-19.47). After a follow-up ranging from 6 to 29 months (median 12), the risk of long-term death was 31.00% (17.10-45.52), with MACE in 37.00% (19.56-55.95; all CI 95%).

CONCLUSION

Our meta-analysis, pooling the largest cohort ever of nonagenarians undergoing PCI with stents, confirms the feasibility of percutaneous coronary stenting even in this very frail patient subset, despite the expected severe event attrition during follow-up. Thus, nonagenarians with an acceptable risk profile, recent clinical instability and/or disabling symptoms should not be denied the possibility of percutaneous coronary revascularization.

Percutaneous coronary intervention in nonagenarians: pros and cons

Percutaneous coronary intervention is a mainstay in the management of symptomatic or high-risk coronary artery disease. The bulk of clinical evidence and experience underlying this fact relies, however, on relatively young patients. Indeed, few data of very limited quality are available which adequately define the risk-benefit and cost-benefit profile of coronary angioplasty and stenting in very old subjects, such as those of 90 years of age or older (i.e., nonagenarians). The aim of this review is to provide a concise, yet practical, synthesis of the available evidence on percutaneous coronary revascularization in the very elderly. The main arguments elaborated upon are to what extent we can extrapolate findings from studies including younger patients to nonagenarians, whether we should provide higher priority to prognosis or quality of life in such patients, and whether we can afford to allocate vast resources to care for such subjects in an era of financial constraints. Our review of 18 studies and 1082 patients suggest that percutaneous coronary intervention is feasible and associated with acceptable short- and long-term results in this population, which is nonetheless fraught with a high mortality risk irrespective of the revascularization procedure. Accordingly, the pros and cons of percutaneous coronary intervention should be carefully weighed when considering this treatment in nonagenarians.

Safety, effectiveness, and outcomes of cardiac catheterization in nonagenarians

With an aging population, nonagenarians (≥90 years of age) are increasingly being considered for cardiac catheterization. Because of the paucity of outcomes data in this population, we sought to evaluate the acute and intermediate outcomes of nonagenarians undergoing cardiac catheterization. A retrospective cohort of 44 nonagenarians undergoing 53 cardiac catheterizations from 2002 to 2010 was identified. Mean age was 91 years (range 90 to 96) with 57% of patients being women. Thirteen percent presented with ST-segment elevation myocardial infarction, 32% with non-ST-segment elevation myocardial infarction, 14% with unstable angina, 25% with chronic angina, and 16% with aortic stenosis. Eighteen percent had left main coronary artery disease and 73% had multivessel coronary disease. Complications occurred in 6 of 44 patients (3 with acute kidney injury, 2 with atrial fibrillation, 1 with femoral artery pseudoaneurysm). Twenty patients were treated with medical management, 1 patient underwent coronary artery bypass surgery, and 2 patients underwent aortic valve replacement. Twenty-one patients underwent percutaneous coronary intervention in 27 different vessels. There was procedural success in 93% of these patients. There were no major adverse cardiac events. Five complications occurred after the intervention (4 atrial fibrillations, 1 femoral artery pseudoaneurysm). Cumulative mortalities at 1 month and 6 and 12 months were 0%, 9%, and 20% respectively. In patients who underwent percutaneous coronary intervention or surgery, mortalities were 0%, 0%, and 13% at 1 month and 6 and 12 months, respectively.

Comparison of effectiveness and safety of transcatheter aortic valve implantation in patients aged ≥90 years versus <90 years

In a fraction of patients aged ≥90 years, less-invasive transcatheter aortic valve implantation (TAVI) has been considered a therapeutic option for aortic stenosis under careful clinical screening. However, the safety and effectiveness using TAVI in such a population has not been fully elucidated. The aim of the present study was to investigate the feasibility of TAVI in nonagenarians. We prospectively enrolled 136 consecutive patients with severe aortic stenosis who were referred for TAVI. The procedural, early, and midterm clinical outcomes were compared between patients aged <90 years (n = 110, average age 82.3 ± 8.3 years) and ≥90 years (n = 26; average age 91.6 ± 1.9 years). A comparison of the baseline characteristics revealed that among patients aged ≥90 years, the prevalence of women (50% vs 81%, p <0.001) and the mean aortic valve gradient (45.5 ± 15.4 vs 56.3 ± 23.4 mm Hg, p = 0.005) were greater than those in patients aged <90 years. Major vascular complications occurred more frequently in patients ≥90 years (5% vs 19%, p = 0.022), although the rate of procedural success and 30-day and 6-month mortality were not different between the 2 age groups (96% vs 100%, p = 0.58; 6% vs 15%, p = 0.22; and 14% vs 27%, p = 0.14, respectively). The mortality rates were greater among patients aged ≥90 years. At 6 months, both groups of survivors were similar in symptom status, with a New York Heart Association classification less than class II (89% vs 84%, p = 0.68). The cumulative survival (median 13.4 ± 8.0 months of follow-up) was not significantly different between the 2 age groups (p = 0.22, log-rank test). In conclusion, even very elderly nonagenarians can experience acceptable clinical results and benefits after TAVI.

Midterm outcomes and quality of life following percutaneous coronary intervention in nonagenarians

The midterm clinical and functional benefits of percutaneous coronary intervention in patients aged ≥90 years have not been clearly defined. From January 2005 to June 2009, 173 patients aged ≥90 years underwent diagnostic cardiac catheterization, of whom 90 underwent percutaneous coronary intervention. There were 45 men (50%) and 45 women (50%), with a mean age of 92 years (range 90 to 101). Of these, 24 patients (27%) presented with ST-segment elevation myocardial infarction, 31 (34%) with non-ST-segment elevation myocardial infarction, 28 (31%) with unstable angina pectoris, and 2 (2%) with stable angina pectoris; 5 patients (6%) were studied for preoperative risk assessment. A total of 127 lesions were successfully treated using 102 drug-eluting stents and 37 bare-metal stents, with a mean of 1.5 stents per patient. Postprocedural complications included renal insufficiency in 5 patients (5.6%), heart failure in 6 patients (6.7%), and cardiogenic shock in 2 patients (2.2%). Seventy-seven patients (85.6%) experienced no postprocedural complications. In-hospital mortality was 7.8%, and actuarial survival was 61.5 ± 5.2% at 24 months and 31.6 ± 6.1% at 48 months. The SF-36 Health Survey was administered at follow-up, and results demonstrated a quality of life similar to that of the general population corrected for age and gender. In conclusion, this study demonstrates that percutaneous coronary intervention in nonagenarians can be accomplished with low mortality and morbidity and excellent midterm results. Moreover, functional improvement in nonagenarians supports enhanced quality of life comparable to that of the general population.