Doctors comforting disabled elderly patient at hospital

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Should age by itself preclude elderly patients from revascularization?

Coronary artery disease (CAD) continues to be the leading cause of morbidity and mortality worldwide. Among the classic cardiovascular risk factors like hypertension, diabetes mellitus, smoking or hypercholesterolemia, increasing age is the strongest and only non-modifiable risk factor. In spite of the remarkable progress in the treatment of CAD, the disease continues to be the leading cause of morbidity and mortality in the elderly population.1

 

India is expected to have around 157 million older persons by 2025, and this number will nearly double to 297 million by 2050, constituting 18% of India's population.2 The prevalence of symptomatic CAD increases monotonically with age.3 About 85% of  acute myocardial infarction (AMI) deaths occur in the elderly.2 Elderly patients pose multiple challenges in the form of advanced complex coronary disease and multiple comorbidities.4

It is common in present-day clinical practice to encounter an increasing number of elderly people who present with chronic stable angina and acute coronary syndrome and who require cor­onary revascularization, either by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).5 The frequency of octogenarians presenting for PCI is also on the rise.6

During the initial years of angioplasty, there was a degree of caution in performing revascularization procedures in the elderly as the post-PCI complications were 2-4 times more likely to occur in the elderly than in a younger age group.7 As time progressed, development of revascularization protocols, with improvements in operator technique, guide catheter and guide-wire technology combined with the use of evidence-based drug therapies saw a decline in mortality across all age ranges with the greatest in the oldest patient group, emphasizing the improvements made to PCI technique and adjunctive management.7

In early randomized clinical trials, elderly patients were frequently excluded from the trials and this resulted in a lack of evidence regarding the best treatment for this specific population. However, latest studies have evaluated the benefits of PCI in elderly, including the trials conducted in Indian population.

A study conducted in Indian population evaluated the immediate- and short-term outcomes of primary PCI in 50 elderly patients aged ≥75 years and correlated with their various clinical and angiographic characteristics.4 Angiographic success was achieved in 78% of the patients, and in-hospital mortality rate was 8%. Complete heart block at presentation, Killip Class III, delayed presentation (>6 h), moderate-to-severe left ventricular systolic dysfunction, slow-flow or no-reflow phenomenon, diabetes, and nonresolution of ST segment were major predictors of in-hospital mortality.4

Since the elderly patients are at increased risk of contrast-induced nephropathy which is aggravated by the frequent Killip III/IV presentation with associated organ hypo perfusion, the study selectively used isosmotic non-ionic contrast agent (iodixanol) in every patient. 4 Even though acute renal failure had developed in five patients (10%) during the hospital stay, this was transient and it recovered on its own. It is important to note that no death resulted from renal failure and none of the patient’s required hemodialysis.  This study suggests that primary PCI can be safely and successfully performed in elderly Indian patients presenting with ST-elevation myocardial infarction (STEMI). 4

Another prospective observational study evaluated the clinical and coronary angiographic profile of 601 older adult patients with acute coronary syndrome treated at a tertiary hospital in North India. The 30-day mortality rates remained acceptable (5.3%) despite high-risk patients taken for PCI. Even though elderly patients have a high coronary risk because of associated comorbidities, this study proved that PCI (if indicated) resulted in fewer contrast-induced nephropathy (3.3%) and intra cerebral haemorrhage complications (only 1 patient) in older patients with acute coronary syndrome (ACS).2

A retrospective cohort analysed the risk factors which predict major adverse cardiac events (MACE) in 355 patients older than 70 years who underwent PCI at a centre in South India, between 2008 and 2018. Both the binary logistic regression and the univariate analysis confirmed that diabetes mellitus is a strong predictor for death. The study concluded that PCI is safe and is an effective method of coronary revascularization in elderly patients with diabetes mellitus was an independent predictor of MACE in the elderly.8

Studies have shown that octogenarians undergoing elective PCI have good outcomes with higher procedural success rates and minimal morbidity suggesting that PCI is a safe and effective treatment modality of stable coronary heart disease even among the very elderly patients.9

There is a report in the literature of a 105-year-old lady presenting with inferior wall STEMI who was managed with primary PCI to the right coronary artery. She suffered no acute complications. She was discharged home and later celebrated her 106th birthday.10

A study investigating clinical and angiographic outcome after successful recanalization of chronic total occlusion (CTO) lesions in octogenarians found a high success rate of complete recanalization of CTO lesions and low rate of complications for patients over 80 years of age. Comparing these endpoints with the under-80 years cohort, found no difference between the two cohorts. The results suggest that CTO PCI is feasible and safe even for older patients. Although acute kidney injury was the most common intra-hospital complication seen in the octogenarian cohort, none of the patients developed a need for dialysis.11

To summarise, multiple studies provide data supporting the benefits of instituting PCI early among elderly patients. On the basis of current evidence, the decision to perform PCI should not be based on chronological age alone, but rather on each patient's general eligibility for revascularization and the clinical circumstances as a whole.12 Judicious use of contrast may help to reduce risk of contrast-induced nephrotoxicity, while performing PCI in the elderly. 13

 

Abbreviations:

ACS: Acute coronary syndrome

AMI: Acute myocardial infarction

CABG: Coronary artery bypass grafting

CAD: Coronary artery disease

CTO: Chronic total occlusion

MACE: Major adverse cardiac events

PCI: Percutaneous coronary intervention

STEMI: ST-elevation myocardial infarction

 

References:

  1. Blessing, R.R.L., Ahoopai, M., Geyer, M. et al. Percutaneous coronary intervention for chronic total occlusion in octogenarians: a propensity score study. Sci Rep 12, 3073 (2022).

  2. Khan UH, Pala MR, Hafeez I, Shabir A, Rashid A, Tramboo N, Rather H. The clinical and coronary angiographic profile of 601 older adult patients with acute coronary syndrome treated at a tertiary hospital in North India and complications of percutaneous coronary intervention with the 30-day mortality. J Indian Acad Geriatr 2020; 16:139-44

  3. Madhavan MV, Gersh BJ, Alexander KP, Granger CB, Stone GW. Coronary Artery Disease in Patients ≥80 Years of Age. J Am Coll Cardiol. 2018 May 8;71(18):2015-2040.

  4. Gautam A, Yusuf J, Mehta V, Mukhopadhyay S. Primary percutaneous coronary intervention in elderly (age ≥75 years) Indian population – Immediate- and short-term results. J Pract Cardiovasc Sci 2020; 6:153-61

  5. Raju YS. Percutaneous Coronary Intervention in Elderly: It is Never Too Late, Ind J Car Dis Wom 2020;5:25–26

  6. Shanmugam VB, Harper R, Meredith I, Malaiapan Y, Psaltis PJ. An overview of PCI in the very elderly. J Geriatr Cardiol. 2015 Mar;12(2):174-84.

  7. Vandermolen S, Abbott J, De Silva K. What's Age Got to do with it? A Review of Contemporary Revascularization in the Elderly. Curr Cardiol Rev. 2015;11(3):199-208.

  8. Ramakrishna, A. & Rao, V. & Indrani, Garre. Gender-wise Long-term Predictors for Major Adverse Cardiac Events Following Percutaneous Coronary Intervention in the Elderly Population. Ind J Car Dis Wom 2020; 5:18–24

  9. Vlaar PJ, Lennon RJ, Rihal CS, Singh M, Ting HH, Bresnahan JF, Holmes DR Jr. Drug-eluting stents in octogenarians: early and intermediate outcome. Am Heart J. 2008 Apr;155(4):680-6.

  10. Cloutier JM, Zieroth S, Elbarouni B. Primary Percutaneous Coronary Intervention As Treatment for ST-Elevation Myocardial Infarction in a Centenarian: Choosing Carefully. Can J Cardiol. 2017 Aug;33(8):1066.e1-1066.e3

  11. Blessing, R.R.L., Ahoopai, M., Geyer, M. et al. Percutaneous coronary intervention for chronic total occlusion in octogenarians: a propensity score study. Sci Rep 12, 3073 (2022).

  12. Shanmugasundaram M. Percutaneous coronary intervention in elderly patients: is it beneficial? Tex Heart Inst J. 2011;38(4):398-403

  13. Shanmugam VB, Harper R, Meredith I, Malaiapan Y, Psaltis PJ. An overview of PCI in the very elderly. J Geriatr Cardiol. 2015 Mar;12(2):174-84.