Cardiovascular disease is the leading cause of death in elderly adults (individuals aged 75 years or older). In turn, coronary heart disease is one of the main causes of morbidity in this population. In addition to anatomical complexities, there are other factors that may complicate its management, such as polypharmacy, frailty, and procedure-related risks. All of this, along with high surgical risk (which can be an excluding factor in some cases), makes percutaneous coronary intervention (PCI) the primary choice for their revascularization treatment.
In patients with acute coronary syndromes, PCI has been shown to improve long-term clinical outcomes. In stable ischemic heart disease (SIHD), revascularization is mainly indicated for patients who continue to experience symptoms despite optimal medical treatment (OMT) or when an anatomical approach can improve survival, as in the case of left main coronary artery (LMCA) disease.
As a result, the use of complex PCI in patients with SIHD has become more frequent, although information from studies is limited, and there are virtually no comparisons between complex and non-complex PCI in this population. This motivated Hanna et al. to conduct this study.
Researchers obtained data on elective PCIs in elderly patients (≥75 years) from an academic database (which included Yale and Harvard) spanning a network of five hospitals. Patients who underwent emergency PCI and those lost to follow-up within one year were excluded. Complex PCI was defined as multivessel disease (≥3 vessels including branches or ≥2 vessels including unprotected LMCA or proximal left anterior descending artery), intervention in the LMCA, saphenous vein grafts, bifurcation lesions, and PCI with atherectomy (laser or lithotripsy).
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The primary endpoint was event-free survival at 12 months after initial revascularization, which was defined as the absence of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke, and major bleeding according to BARC (3 and 5) criteria. Secondary outcomes analyzed included all-cause mortality, target lesion revascularization (TLR), and all types of bleeding.
A total of 513 patients undergoing PCI for SIHD were included in the analysis. The average age was 81.3±4.6 years; 56.1% underwent non-complex PCI, while 43.9% (n=225) underwent complex PCI. The most common reason for revascularization was inadequate symptom control (66.1% of the cohort). Within this cohort, 3.7% had unsuccessful PCI, and 1.4% required mechanical circulatory support during PCI.
Event-free survival at 12 months in the entire cohort was 84% (95% confidence interval [CI]: 80.9%–87.2%). Patients who underwent non-complex PCI showed better event-free survival (86.8% vs. 80.4%), although, after adjusting for clinical and demographic characteristics, the difference was non-significant (hazard ratio [HR]: 1.38 [95% CI: 0.88–2.16]). The 12-month risk for non-fatal myocardial infarction was 1.4% (95% CI: 0.4–2.4%), and the risk for non-fatal stroke was 2.7% (1.3% vs. 4.1%).
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Patients who underwent complex PCI had higher all-cause mortality compared with those who underwent non-complex PCI (10.2% vs. 5.9%), and these results remained consistent after adjustment (HR, 1.97; 95% CI: 1.02–3.79). The TLR rate for the entire cohort was low (2.9%), and there were no differences between complex and non-complex PCI groups (unadjusted HR, 0.64 [95% CI: 0.22–1.87]). Regarding bleeding, patients who underwent complex PCI experienced more events (25.3% vs. 20.5%).
Conclusion
In summary, when evaluating complex angioplasty in elderly patients, they had nearly twice the risk of all-cause mortality compared with patients who underwent non-complex PCI. It is important to note that complex interventions showed a reduced need for TLR. The assessment of factors affecting survival in these increasingly common scenarios is essential and should be thoroughly analyzed.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Complex Percutaneous Coronary Intervention Outcomes in Older Adults.
Reference: Hanna, Jonathan M et al. “Complex Percutaneous Coronary Intervention Outcomes in Older Adults.” Journal of the American Heart Association vol. 12,19 (2023): e029057. doi:10.1161/JAHA.122.029057.
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