Effectiveness of percutaneous coronary interventions in nonagenarians

doi:10.1016/j.amjcard.2004.06.068

The American Journal of Cardiology

Volume 94, Issue 8, 15 October 2004, Pages 1058-1060

https://doi.org/10.1016/j.amjcard.2004.06.068 Get rights and content

Data on percutaneous coronary intervention (PCI) in nonagenarians are very scarce. The investigators present a series of 26 nonagenarians who underwent PCI (29 lesions, 1.1 ± 0.3 per patient). Most (96%) had acute coronary syndrome at presentation, 27% underwent primary PCI for acute myocardial infarctions, and 54% had multivessel disease. Angiographically successful results were obtained in 24 patients (92%), and coronary stents were used in 81%. Five patients (19%) died during hospitalization. In-hospital mortality was significantly greater in patients with Killip class III or IV at presentation (100% vs 9%, p = 0.001), in those in whom the procedure was a primary PCI for acute myocardial infarction (57% vs 5%, p = 0.010), and in the presence of angiographic failure (100% vs 13%, p = 0.031). In-hospital mortality was 0% after excluding patients in cardiogenic shock and those with primary PCI. Thus, most nonagenarians who undergo PCI have a high-risk profile. However, PCI achieves a successful angiographic result in most patients. Mortality is high but concentrated in patients in cardiogenic shock and with primary angioplasty as PCI.

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Cited by (37)

Contemporary Trends in Clinical Characteristics, Therapeutic Strategies and Outcomes in Patients Aged 80 Years and Older Presenting with non-ST Elevation Myocardial Infarctions in the United States
2023, Current Problems in Cardiology
The current guidelines for the management and treatment of acute coronary syndromes do not fully consider the role of age in guiding medical or invasive management. We investigated the characteristics, management strategies, and clinical outcomes of patients aged 80 years and older presenting with non-ST elevation myocardial infarction (NSTEMI). A cohort study using the nationwide inpatient sample database of patients aged 80 years and older presenting with NSTEMI in the United States between 2012 to 2018 was performed. About 24.2% (151,472/625,916) of NSTEMI patients were 80 years and older. Older patients (≥80 years) had higher in-hospital mortality and cardiovascular complications compared to younger patients (odds ratio (OR) 1.79, 95% confidence intervals (CI) 1.71-1.88, P < 0.001). Among older patients, conservative medical management was associated with higher inpatient mortality compared to percutaneous coronary intervention (PCI) (OR 2.3, 95% CI 2.18-2.41, P < 0.001) or coronary artery bypass graft (CABG) (OR 1.9, 95% CI 1.76-2.09, P < 0.001). The highest mortality rate was observed in older patients who underwent both PCI and CABG, followed by those treated conservatively and those undergoing coronary angiography without revascularization. This study provides valuable insights into the clinical characteristics and outcomes of elderly patients presenting with NSTEMI in the United States. The results emphasize the importance of a tailored approach to the management of ACS in elderly patients and the need for improved revascularization strategies to reduce in-hospital mortality and adverse cardiovascular outcomes. Therefore, the clinician should tailor the management of older patients presenting with NSTEMI.
Complications of coronary invasive procedures in nonagenarians: A case-control study
2020, Annales de Cardiologie et d'Angeiologie
La pathologie coronarienne constitue la première cause de morbi-mortalité chez les patients nonagénaires, dont le nombre a doublé en vingt ans. En l’absence de recommandations, la place de la stratégie invasive coronaire dans cette population reste un challenge thérapeutique, et son intérêt ainsi que ses risques mal établis. Le but de notre étude était d’évaluer la sécurité de la pratique invasive coronaire dans la population nonagénaire toutes indications confondues.
Il s’agissait d’une étude cas-témoin monocentrique menée du 1^er janvier 2010 au 30 mai 2019. Les patients inclus étaient l’ensemble des nonagénaires ayant bénéficié d’une coronarographie au centre hospitalier de Troyes au cours de cette période. Pour chaque patient inclus, deux témoins appariés sur le sexe, la date de procédure et l’acte ont été tirés au sort. Le critère de jugement principal était la survenue de complications per- ou post-procédures immédiates durant le séjour au cours duquel était réalisée la procédure. Les principaux critères de jugement secondaire étaient la durée moyenne de séjour, la survenue d’évènements intercurrents durant le séjour (infections nosocomiales, syndrome confusionnel) et la survenue d’une perte d’autonomie.
Au total, 59 nonagénaires et 118 témoins ont été inclus dans notre étude. Nous avons recensé 30,5 % de complications majeures chez les nonagénaires versus 10,2 % chez les témoins (p = 0,001 ; OR = 0,26 [0,1–0,6]), avec une différence significative portant sur la survenue d’un choc cardiogénique (p = 0,04), d’une insuffisance cardiaque (p = 0,02) et de troubles rythmiques ventriculaires (p = 0,04). L’insuffisance rénale aiguë post-procédure était plus importante chez les nonagénaires (p = 0,02 ; OR = 0,20 [0,05–1,57]). La durée moyenne de séjour était en moyenne deux fois plus longue chez les nonagénaires.
Les patients nonagénaires sont sujets à plus de complications lors de la réalisation d’une procédure invasive coronaire par rapport à des patients de moins 75 ans.
Coronary heart disease is the leading cause of morbidity and mortality in nonagenarians, whose numbers have doubled in twenty years. In the absence of recommendations, the place of coronary invasive strategy in this population remains a therapeutic challenge and its interest as well as its risks are poorly established. The aim of our study was to evaluate the safety of coronary invasive practice in the nonagenarian population for all indications.
This was a monocentric case-control study conducted from January 1, 2010 to May 30, 2019. The patients included were all nonagenarians who had undergone coronary angiography at the centre hospitalier de Troyes during this period. For each patient included, two controls matched on sex, date of procedure and procedure were drawn at random. The main judgment criterion was the occurrence of immediate per- or post-procedure complications during the stay in which the procedure was performed. The main secondary outcome measures were average length of stay, occurrence of intercurrent events during the stay (nosocomial infections, confusional syndrome), and loss of autonomy.
In all, 59 nonagenarians and 118 controls were included in our study. We identified 30.5% major complications in the nonagenarians versus 10.2% in the controls (P = 0.001; OR = 0.26 [0.1–0.6]), with a significant difference in the occurrence of cardiogenic shock (P = 0.04), heart failure (P = 0.02) and ventricular rhythm disorders (P = 0.04). Post-procedure acute renal failure was greater in the nonagenarians (P = 0.02; OR = 0.20 [0.05–1.57]). The mean length of stay was on average twice as long in the nonagenarians.
Nonagenarian patients are subject to more complications when undergoing coronary invasive procedures compared to patients under 75.
Outcomes of Nonagenarians With ST Elevation Myocardial Infarction
2020, American Journal of Cardiology
Citation Excerpt :
Very old patients have been under-represented in large, randomized clinical trials that evaluated treatment of STEMI. Most of the information about this patient cohort comes from large national registries.21 One of them includes 33,644 nonagenarian patients with STEMI,22 with an overall PCI rate of 16.9% and more likely in men and those with mild co-morbidities.
Although older adults are the fastest-growing age group among cardiovascular patients, nonagenarians with ST-segment elevation myocardial infarction (STEMI) are under-represented in clinical trials. The aims of this study are to analyze the clinical presentation and outcomes of nonagenarian patients presenting with STEMI and to compare in-hospital and 1-year clinical outcomes between those treated with optimal medical treatment alone and those receiving primary percutaneous coronary intervention (pPCI). We included all consecutive nonagenarians presenting with STEMI admitted in 2 academic centers between 2006 and 2018. There were no exclusion criteria. All-cause mortality was assessed in-hospital and at 1-year follow-up. In total, 167 patients (mean age 91.9 ± 0.17 years; 60% females) were included. Emergent catheterization was performed in 60% of our patients, and pPCI was performed in 50% (n = 83). Overall mortality was 22% in-hospital and 41% at 1-year follow-up. The pPCI group had lower mortality than the medical treatment group: 12% versus 32% in-hospital (p <0.01) and 26% versus 45% at 1-year follow-up (p <0.01), respectively. Multivariable analysis identified 4 independent predictors of all-cause mortality at 1 year: mechanical complications (adjusted odds ratio [OR] 9.25, p <0.01), Killip class III/IV (adjusted OR 4.22, p <0.01), serum creatinine at admission (mg/dl; adjusted OR 1.8, p <0.01), and pPCI (adjusted OR 0.52; p <0.05). In conclusion, STEMI in nonagenarians is becoming increasingly common. pPCI may be the preferred strategy in this high-risk cohort when a high grade of disability is not present. Hemodynamic compromise, the presence of complications related to myocardial infarction, renal impairment, and early revascularization may be related to prognosis in these patients.
Percutaneous Coronary Intervention Outcomes in Very Elderly Patients From a Single Large-Volume Tertiary Care Center, Specifically Focusing on Nonagenarians
2017, JACC: Cardiovascular Interventions
Percutaneous coronary intervention for nonagenarian patients with ST-segment elevation myocardial infarction: Experience of a single Japanese center
2016, Journal of Cardiology
Citation Excerpt :
The 30-days and 2 years-mortality rate after primary PCI for STEMI showed no significant difference between nonagenarian and younger patients groups, although the nonagenarian patients had a significantly longer door-to-balloon time, a higher incidence of renal insufficiency, a larger number of diseased coronary vessels, and lower hemoglobin level. To date, several studies evaluating the clinical outcomes of nonagenarian patients with acute coronary syndrome have reported relatively worse in-hospital mortality rates (14.0–34.2%) than the current study [6–10]. The main difference between the current study and these prior studies is the prevalence of trans-radial coronary intervention (TRI) and the use of IABP.
Old age is a prognostic risk factor for patients with ST elevation acute myocardial infarction (STEMI); however, few data exist describing STEMI patients aged over 90 years.
We retrospectively evaluated the clinical indices and outcomes of 282 consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) in our hospital between January 2008 and December 2012. Patients with acute myocardial infarction complicated by out-of-hospital cardiopulmonary arrest, patients with a left main trunk culprit lesion, and patients diagnosed more than 24 h after symptom onset were excluded.
Of the patients treated during the study period, 11 (3.8%) were >90 years old. The mean door-to-balloon time was significantly longer for nonagenarians than younger patients (66.2 vs. 44.0 minutes; p < 0.001). This was mainly attributed to delays in decision-making regarding invasive treatment by both the doctors and families. Nonagenarians had multiple coronary artery stenoses more frequently (36.4% vs. 15.0%; p < 0.05) and required intra-aortic balloon pumping more often (36.4% vs. 18.9%; p = 0.15) compared with patients aged ≤89 years. However, the peak creatinine kinase levels and the left ventricular ejection fractions were similar between the groups. Moreover, the in-hospital and 30-day mortality rates were similar (9.1% vs. 4.6%, p = 0.50; 9.1% vs. 3.6%, p = 0.34, respectively) between the groups. The two-year survival rate was 81.8% in nonagenarians.
Despite the longer door-to-balloon time, higher use of intra-aortic balloon pumping, and larger number of diseased vessels, the 30-day and 2-year survival rates of nonagenarians with STEMI were comparable to those of younger patients.
A case review: About a STEMI in the very elderly
2015, Annales de Cardiologie et d'Angeiologie
De part la progression démographique de nos sociétés et la prévalence croissante avec l’âge des coronaropathies, nous serons de plus en plus confrontés au traitement de l’infarctus ST+ des patients très âgés (> 90 ans ?). Si les données scientifiques rigoureuses sont inexistantes dans ce cadre là, il existe de nombreux registres qui peuvent nous guider dans leur prise en charge. En premier lieu l’âge ne doit pas être en lui-même une contre-indication aux techniques de reperfusion classiques. Les recommandations ne mettent d’ailleurs pas de limite supérieure d’âge. L’angioplastie primaire dont le succès technique est identique aux populations plus jeunes est le traitement de choix et devra être pratiquée de préférence par abord artériel radial. L’alternative thrombolytique, validée pour les octogénaires, n’a pas été étudiée pour les plus âgés. Les complications hémorragiques, neurologiques, ischémiques et la mortalité hospitalière sont plus fréquentes que pour les populations plus jeunes, d’autant plus que l’altération hémodynamique initiale est importante, mais les survivants ont un pronostic vital identique, voire même meilleur que celui d’une population de même âge de référence. Ce qui en soi même justifie une adhésion maximale aux recommandations thérapeutiques en tenant compte des comorbidités et des insuffisances viscérales possibles.
Because of the demographic growth of our societies and the increasing prevalence of coronary artery disease with age, we will be increasingly faced with the treatment of myocardial ST+ very elderly patients (>90 years?). If evidence-based medicine does not exist within this framework, there are many registries that can guide us in their care. First, age should not in itself be an indication against reperfusion conventional techniques. In fact recommendations put no upper age limit. The primary angioplasty technical success, which is identical to the younger populations, is the treatment of choice and should be performed preferably by radial arterial access. The thrombolytic alternative, validated for octogenarians, has not been studied for older. Bleeding, neurological, ischemic complications and hospital mortality are more common than in younger populations, especially as the initial hemodynamic alteration is important, but the survivors have the same life-threatening or even better than that of a same reference population ages. Which in itself even justifies maximum adhesion to the therapeutic recommendations taking into account the co-morbidities and possible visceral shortcomings.

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Effectiveness of percutaneous coronary interventions in nonagenarians

Int J Cardiol

J Am Coll Cardiol