Is age ‘just a number' when it comes to PCI patients in their 90s?
The proportion of percutaneous coronary interventions (PCIs) performed in nonagenarians has more than doubled in the last decade in the United States, offering a significant survival benefit for those deemed healthy enough for the procedure, according to a study published online Sept. 17 in JACC: Cardiovascular Interventions.
Mayo Clinic researcher Kashish Goel, MD, and colleagues used the National Inpatient Sample to analyze how PCI usage trends and mortality outcomes changed from 2003 through 2014 for patients aged 90 or older. They identified nearly 70,000 PCIs among nonagenarians, who accounted for 0.9 percent of all PCI hospitalizations over the study period—increasing from 0.6 percent of PCIs in 2003-2004 to 1.4 percent in 2013-2014.
In-hospital mortality was 16.4 percent for ST-segment elevation myocardial infarction (STEMI), 4.2 percent for non-STEMI acute coronary syndromes (ACS) and 1.8 percent for PCIs for stable ischemic heart disease (SIHD).
But compared to patients who were medically managed, PCI for STEMI and PCI for other ACS indications was associated with risk reductions of 65 and 74 percent, respectively, for in-hospital mortality after multivariable adjustment.
“Approximately 35 percent of the patients undergoing PCI for STEMI who survived the hospitalization required a skilled nursing facility or short-term hospital likely due to the high prevalence of frailty necessitating skilled assistance at discharge after a catastrophic event such as STEMI,” the researchers wrote. “These data suggest that revascularization in nonagenarians presenting with STEMI should be considered, keeping in mind the high risk of procedural and post-procedural complications.”
The number of older PCI candidates will only grow, the authors pointed out, as the latest U.S. census projects the population of Americans 85 or older is expected to double by 2035.
“A large number of patients in this age group are denied the option of revascularization because of perceived increased risks related to comorbidities and advanced age,” Goel et al. wrote. “One of the main reasons for this may be paucity of data about the outcomes of PCI in this age group.”
The largest previous study of PCI in this population contained only 575 patients, the authors said. But this National Inpatient Sample analysis provided a much larger sample and the opportunity to evaluate temporal trends.
From the first two years of the study to the final two, the authors found:
- A worsening baseline risk profile among patients undergoing PCI.
- Adjusted in-hospital mortality remained unchanged for STEMI and non-STEMI ACS, but increased by 21 percent for PCI of SIHD.
- The rates of bleeding and vascular complications decreased in all three subgroups, but the risk-adjusted incidence of stroke increased in patients with STEMI and SIHD.
- The proportion of PCIs for ACS increased from 72.7 percent to 83.5 percent. Meanwhile, the proportion of PCIs for SIHD dropped from 27.3 percent to 16.5 percent.
Still, only 6.8 percent of nonagenarians hospitalized with ACS during the study period were estimated to undergo PCI, including 10.7 percent of those with STEMI. Patients who received PCI were more likely to have known coronary artery disease or prior coronary revascularization and less likely to have comorbidities such as heart failure, dementia or neurologic disorders.
The authors acknowledged selection bias likely aided survival in the PCI group because those patients, their families and their physicians opted to try an invasive approach, believing its benefits outweighed the risks. They also couldn’t determine the reasons for the increasing mortality associated with PCI in the SIHD subgroup, but said “these data underscore the importance of patient selection, appropriate risk-mitigating techniques, and treatment of only appropriate lesions in this high-risk age group.”
The authors of an accompanying editorial agreed selection bias contributed to PCI for ACS improving mortality outcomes versus medication alone.
“At best, all that can be said is that highly selected nonagenarians who are referred for PCI have better outcomes than non-selected nonagenarians who receive (perhaps nonoptimal) medical therapy,” wrote Aditya Mandawat, MD, with Duke University Hospital, and Anant Mandawat, MD, with Emory University Hospital.
But that’s not to suggest the study isn’t useful. The Mandawats said it serves as a reminder that “age is just a number when it comes to PCI,” whereas measures of frailty might better guide decisions on whether to attempt invasive treatment.
“This study is important because it demonstrates that there is no explicit (chronological) age cutoff above which older adults should not be offered PCI. … Over the past decade, it has become clear that frailty—a complex interplay of biological, cognitive, and social factors—is closely associated with adverse periprocedural outcomes in older adults.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.