• Coronary artery disease
• coronary intervention
• coronary stenting
• ST-segment elevation myocardial infarction

As the population continues to age, physicians often need to make crucial clinical decisions in the medical management of octogenarians and beyond. As the majority of clinical studies focus on younger demographics, we are often forced to extrapolate the existing evidence and guidelines while treating the very elderly. In the context of coronary heart disease, primarily a disease of ‘old age’, the clinical burden of such decisions is a daily occurrence with often life-altering consequences.

In the acute management of ST-elevation myocardial infarctions (STEMI), the weight of evidence has proved primary revascularisation therapies to result in decreased mortality and morbidity compared with medical management without mechanical reperfusion.1 Furthermore, timely percutaneous coronary intervention (PCI) is now established as a superior strategy compared with fibrinolytic therapy, with regard to both survival and composite outcome measures.2 Nevertheless, there has remained significant controversy in treating the elderly, given the observed risk of complications with increasing age and the paucity of trials proving the benefits of revascularisation and PCI to the octogenarian cohort.

In this issue of Heart, Claessen et al3 publish their 10-year single-centre experience in performing primary PCI in patients presenting with acute STEMI, comparing those aged 80 years and over with younger subgroups (see page 843). The investigators note an increasing proportion of octogenarians treated with primary PCI from 1997 (3.5%) to 2007 (8.8%). This trend is consistent with other published experiences and may reflect an ageing populace, a later age at presentation and an increasing comfort …