Background Interventionists are often reluctant to undertake PCI in very elderly patients due to the perception of poor outcome in a high risk cohort. Paradoxically however, elderly patients may benefit most from revascularisation because of their higher baseline risk compared to younger patients. The prognostic significance of advanced age itself is not clear.
Objective An observational study determining the in-hospital outcomes of very elderly patients (age>85) undergoing percutaneous coronary intervention (PCI) for all indications at a tertiary cardiac referral centre.
Methods Baseline clinical, angiographic and procedural variables and in-hospital outcome data were entered into a prospective registry of 17 572 consecutive patients undergoing PCI at the University Health Network between April 2000 and December 2008. Patients were stratified according to age (<85 years, n=17 168, or ≥85 years, n=404) and in-hospital mortality, major adverse cardiac event (MACE) and complication rates were calculated. Logistic regression-analysis identified independent predictors of unadjusted mortality and MACE. Very elderly patients were propensity matched (1:2 ratio) with younger patients, and the analysis repeated.
Results Very elderly patients had a mean age of 87.5±2.9 (range 85 to 97) vs 62.8±11.1 years for the younger cohort and had greater comorbidity. The very elderly were more likely to present as a primary or urgent PCI, and PCI was less likely to be undertaken electively. Left main stem and complex lesion-type intervention was greater, and angiographic success less likely. Unadjusted mortality and post procedure MI were significantly higher (6.93% vs 1.20%, p<0.0001 and 4.46% vs 2.74%, p=0.04), but CABG rates did not significantly differ (0.25% vs 0.47%, p=0.5). Length of stay, renal, neurological and access-site complications were all greater in the very elderly cohort. Though age≥85 years was a significant independent predictor of both mortality (OR 2.62, CI 1.44 to 4.78, p=0.0016) and MACE (OR 1.94, CI 1.25 to 3.01, p=0.003), its effect was not as great as other well documented variables such as cardiogenic shock and urgency of procedure. After propensity matching, mortality remained significantly higher in the very elderly patients (7.0% vs 3.25%, p=0.003). MACE rates were also significantly higher (9.75% vs 5.88%, p=0.014). Advanced age remained a strong predictor of worse outcomes (mortality OR 2.90, CI 1.38 to 6.06, p=0.005, MACE OR 2.01, CI 1.17 to 3.46, p=0.011).
Conclusion Very elderly patients represent a high risk cohort in terms of comorbidity and complications post-PCI. Although in-hospital mortality was significantly increased compared with younger patients, death occurred predominantly in very elderly patients undergoing non-elective PCI. Decisions to proceed with PCI in very elderly patients should be based on other prognostic variables and these patients should not be excluded from revascularization based on age alone.
|Variable (%)||Age<85 years (N=17 168)||Age≥85 years (N=404)||p Value|
|Death||206 (1.2%)||28 (6.9%)||<0.0001|
|MACE||531 (3.1%)||39 (9.7%)||<0.0001|
|Urgent CABG||81 (0.5%)||1 (0.3%)||0.5152|
|Any myocardial infarction||471 (2.7%)||18 (4.5%)||0.0387|
|Any complication||1426 (8.3%)||85 (21.0%)||<0.0001|
|Increase in CrCl >25%||570 (3.3%)||29 (7.2%)||<0.0001|
|New dialysis||16 (0.1%)||0 (0%)||0.5393|
|Neurological complication||47 (0.3%)||5 (1.2%)||0.0004|
|Cerebral bleed||8 (0.05%)||1 (0.25%)||0.0777|
- coronary intervention
- clinical outcomes
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