Interventional cardiology

PCI in the over 80s: should older age preclude patients from revascularisation?

Elderly patients over 80 years of age have higher all-cause mortality at all time points following PCI compared to younger patients, a large Melbourne study has found.

The study of 29,000 consecutive patients undergoing PCI at one of the six hospitals contributing to the Melbourne Interventional Group Registry, found in-hospital mortality (5.2% v 1.9%), 30-day mortality (6.4% v 2.2%) and long term mortality (43% v 14%) was higher in ≥ 80 year-olds compared to <80 year-olds.

“There was early and increasing separation in survival curves between the elderly and non-elderly cohort commencing in-hospital, with continuing divergence at 30- days and continuing through to the long-term follow-up consistent with increased mortality over time seen among the elderly in other studies,” the study said.

Age 80 years was found to be an independent predictor of long-term mortality along with other factors such as impaired renal function, cardiogenic shock and out of hospital cardiac arrest.

“That increasing age itself portends both short- and long-term mortality following PCI is noteworthy and underscores its importance when considering the prognostic benefit of revascularisation versus medical therapy in this high-risk group of patients,” the study said.

Senior investigator on the study Associate Professor William Chan told the limbic that decision making around the value of invasive treatment for elderly patients was still nuanced.

“When treating elderly patients >80 years, clinicians should be cognisant of the patients’ comorbidities, which are often more than those younger than 80, and weigh this up against the wishes of the patients, and the risk of mortality of their cardiology condition.”

“Treatment decisions should be individualised as very often this is not straightforward.”

“However, when we juxtapose survival of elderly patients undergoing PCI against those of a healthy community dwelling elderly cohort from the Busselton study, their survival appeared comparable,” he said.

“As such, elderly patients should still be offered invasive treatment after judicious consideration as very often they will still derive significant symptomatic benefit and their overall survival post PCI is very acceptable.”

Associate Professor Chan, from Alfred Health, said poorer long term survival in the elderly could be due to the competing mortality risk of their comorbidities such as cancer, stroke and kidney disease.

The study, published in Heart, Lung and Circulation, concluded that while age was an important prognostic variable when deciding on management strategies in the elderly, it should not necessarily preclude patients from revascularisation.

In other analysis from the Melbourne Interventional Group Registry, PCI outcomes were compared in an early cohort (2005-2008) and a contemporary cohort (2015-2018).

The study found procedural practice had changed over time, for example with significantly more radial access in recent years compared to earlier years (57% v 4%) and a much higher rate of use of drug-eluting stents (83% v 44%).

However unadjusted mortality was also higher in the contemporary cohort at both 30 days (3.9% v 2.2%) and at 12 months (7.1% v 4.4%).

“The higher mortality rate in contemporary PCI is a concern, and although largely explained by a higher patient-risk profile, highlights the importance of strategies to improve outcomes, particularly where a mortality gap persists,” the letter to the editor of the Internal Medicine Journal said.

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