Complex percutaneous coronary intervention (PCI) among older adults is associated with a significantly higher risk of death within 12 months than noncomplex PCI, according to a new analysis published in the Journal of the American Heart Association.[1]
“Unfortunately, available data are limited to inform complex PCI in older adults, and a consistent definition of complex PCI is lacking,” wrote corresponding author Michael Nanna, MD, MHS, an interventional cardiologist with Yale School of Medicine, and colleagues. “A number of studies have evaluated the association between advanced chronologic age and increasing risk, reporting worse outcomes and higher rates of complications with PCI among older adults compared with younger populations. However, no studies have specifically looked at how the risk of complex PCI compares with that of noncomplex PCI within the older adult population to more precisely determine the specific risk conferred by the increasing complexity of the intervention.”
Nanna et al. examined data from more than 500 patients with stable ischemic heart disease (SIHD) who underwent PCI from June 2018 to March 2021. They were all 75 years old or older at the time of the procedure. All patients were treated at one of five hospitals within a large academic health system.
Overall, 43.9% of patients underwent complex PCI. Complex PCI was defined as “any PCI including a procedure or lesion that may carry inherently elevated risk of complications or PCI failure.” The authors emphasized that complex PCI, a term defined by details of the procedure, is not the same thing as high-risk PCI, a term defined by the patient. The group also noted that patients undergoing to the two different treatment options did not differ significantly when it came to demographics or comorbidities.
The study’s primary endpoint—freedom from mortality, nonfatal myocardial infarction, nonfatal stroke or major bleeding events 12 months after PCI—was seen in 84% of patients. This translated to 86.8% among noncomplex PCI patients and 80.4% among complex PCI patients, a difference that was not significant after adjustments were made based on patient demographics and clinical details.
All-cause death after 12 months was 7.8% overall, and it was much more common among PCI patients (10.2%) than noncomplex PCI patients (5.9%). Even after making certain adjustments, the difference between the two treatment options remained in place. There was no significant difference when it came to cardiovascular deaths after 12 months.
“Given the dramatic difference in death risk for older adults receiving complex PCI, we suggest that such interventions in this exceptionally vulnerable population should be approached with additional caution and that further investigations are needed to define causality,” the authors wrote.
In addition, Nanna and colleagues found that the number of patients requiring target lesion revascularization (TLR) was low overall (2.9%). After making certain adjustments, the group did find that complex PCI was linked to a lower risk of TLR than noncomplex PCI.
“Ultimately, the absolute difference in TLR between complex versus noncomplex PCI was small (1%), and complex PCI was at least as effective as noncomplex interventions at maintaining target vessel patency,” the authors wrote. “Importantly, TLR has been identified as an independent predictor of worse outcomes, including death. Thus, the lower rates of TLR observed in the complex PCI groups certainly provide reassurance that older adults undergoing more technically complex procedures can experience excellent midterm revascularization outcomes.”
Bleeding events, meanwhile, impacted both groups of patients at a similar rate.
“Further investigation into the outcomes following complex PCI in older adults is needed,” the study’s authors concluded.
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Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.