pci in elderly patients
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PCI IN ELDERLY
- DEV PAHLAJANI MD,FACC,FSCAI CHIEF OF CARDIOLOGY, BREACH CANDY HOSPITAL,MUMBAI
ELDERLY POPULATION: A GROWING GLOBAL CHALLENGE
• IN USA, 35 MILL…………….IN 2000• 82 MILL…………………………. IN 2030
ABOVE 80 YRS. 9.3 MILLION TO DOUBLE BY 2030
GRACE: FOR HIGH RISK ACSAGE
18466 patients
dynamic ECG changes
+ve cardiac markers
44% > 70 yrs.
< 70 yrs.-10380
70-80 - 5057
80 + - 3029
DEFINITION OF ELDERLY
NO UNIVERSALLY ACCEPTED DEFINITION
WHO: 60 YRS.
MOST US CLASSIFICATION 65 AND ABOVE
GRACE ACS 70YRS.
Management and 6-month Outcomes in Elderly and Very Elderly Patients with
High-Risk non-ST-elevation Acute Coronary Syndromes:
The Global Registry of Acute Coronary Events
Gerard Devlin, Joel M. Gore, John Elliott, Namal Wijesinghe, Kim A. Eagle, Álvaro Avezum,
Wei Huang and David Brieger for the GRACE Investigators
Inhospital events for high-risk patients with NSTE-ACS
<70 years (n = 10 380)
With PCI/CABG 45% (n = 4612)
Without PCI/CABG 55% (n = 5694)
CHF/pulmonary oedema, n (%) 316 (6.9) 488 (8.6), P < 0.01
Recurrent ischaemia, n (%) 1169 (26) 1311 (23), P < 0.01
Major bleeding, n (%) 102 (2.2) 73 (1.3), P < 0.001
Stroke, n (%) 21 (0.4) 20 (0.4), P = 0.6
Death, n (%) 87 (1.6) 203 (2.9), P < 0.001
Eur. HJ 2008, 29, 1275
Inhospital events for high-risk patients with NSTE-ACS
70–80 years (n = 5057)
With PCI/CABG 35% (n = 1741)
Without PCI/CABG 65% (n = 3291)
CHF/pulmonary oedema, n (%) 243 (14) 623 (19), P < 0.0001
Recurrent ischaemia, n (%) 533 (31) 775 (24), P < 0.0001
Major bleeding, n (%) 57 (3.3) 89 (2.7), P = 0.25
Stroke, n (%) 22 (0.7) 16 (0.9), P = 0.3
Death, n (%) 95 (4.3) 262 (6.2), P < 0.001
Eur. HJ 2008, 29, 1275
Inhospital events for high-risk patients with NSTE-ACS
>80 years (n = 3029)
With PCI/CABG 21% (n = 620)
Without PCI/CABG 79% (n = 2390)
CHF/pulmonary oedema, n (%) 124 (20) 539 (23), P = 0.2
Recurrent ischaemia, n (%) 182 (29) 511 (22), P < 0.0001
Major bleeding, n (%) 43 (7.0) 80 (3.4), P < 0.0001
Stroke, n (%) 3 (0.9) 21 (0.5), P = 0.45
Death, n (%) 57 (7.0) 363 (11), P < 0.001
Eur. HJ 2008, 29, 1275
Reperfusion Therapy In Elderly Patients With Acute Myocardial Infarction :
A Randomized Comparison Of Primary Angioplasty And Thrombolytic Therapy
Menko-Jan de Boer, MD*, Jan-Paul Ottervanger, MD*, Arnoud W.J van’t Hof, MD*, Jan C.A Hoorntje, MD*, Harry Suryapranata, MD*,
Felix Zijlstra, MD*, the Zwolle Myocardial Infarction Study GroupZwolle, the Netherlands
Clinical Course of the Two Patient Groups
Angioplasty(n 46) p Value
Streptokinase(n 41)
Mortality in-hospital,n (%) 3 (7) 0.07 8 (20)
Stroke, n (%) 1 (2) 0.34 3 (7)
Recurrent AMI, n (%) 1 (2) 0.01 6 (15)
Bleeding (noncerebral)5 (11) 0.72 3 (7)
JACC 2002, 39, 1723
Overall survival for patients randomized for angioplasty treatment (solid line) and thrombolysis Treatment (dotted line) during 24 ± 6 months of follow-up (p = 0.04, relative risk: 2.5, 95% confidence interval: 1.0 to 6.2).
0 1 2
100
90
80
70
P = 0.04
PCI
STK
Ove
rall
Surv
ival
(%)
year
JACC 2002, 39, 1723
Overall survival free of recurrent infarction or stroke for patients randomized for angioplasty treatment (dashed line) and thrombolysis treatment (doted line) during 24 ± 6 months of follow-up (p = 0.003, relative risk: 3.1, 95% confidence interval: 1.4 to 7.0).
Surv
ival
free
of r
einf
arcti
on
or s
trok
e (%
)
JACC 2002, 39, 1723
0 1 2
100
90
80
70
60
50
STK
PCI
P = 0.003
year
Six-month outcomes for high-risk patients with NSTE-ACS
<70 years (n = 10 380)
With PCI/CABG 45% (n = 4612)
Without PCI/CABG 55% (n = 5694)
Death, n (%) 74 (1.7) 191 (3.5), P < 0.0001
Myocardial infarction, n (%) 85 (2.2) 128 (2.9), P = 0.06
Stroke, n (%) 18 (0.4) 46 (0.9), P < 0.01
Triple endpoint, n (%) 170 (3.8) 337 (6.2), P < 0.0001
Re-admission for cardiac event, n (%) 695 (17) 842 (16), P = 0.7
Eur. HJ 2008, 29, 1275
Six-month outcomes for high-risk patients with NSTE-ACS
70–80 years (n = 5057)
With PCI/CABG 35% (n = 1741)
Without PCI/CABG 65% (n = 3291)
Death, n (%) 50 (3.0) 268 (8.5), P < 0.0001
Myocardial infarction, n (%) 51 (3.5) 141 (5.4), P < 0.01
Stroke, n (%) 27 (1.7) 39 (1.3), P = 0.30
Triple endpoint, n (%) 118 (7.0) 415 (13), P < 0.0001
Re-admission for cardiac event, n (%) 275 (17) 647 (22), P < 0.01
Eur. HJ 2008, 29, 1275
Six-month outcomes for high-risk patients with NSTE-ACS
>80 years (n = 3029)
With PCI/CABG 21% (n = 620)
Without PCI/CABG 79% (n = 2390)
Death, n (%) 69 (12) 420 (19), P < 0.0001
Myocardial infarction, n (%) 27 (5.2) 146 (8.1), P = 0.03
Stroke, n (%) 12 (2.2) 62 (3.1), P = 0.24
Triple endpoint, n (%) 98 (17) 564 (25), P < 0.0001
Re-admission for cardiac event, n (%) 128 (23) 531 (26), P = 0.1
Eur. HJ 2008, 29, 1275
Six-month post-discharge outcomes in young, according to those who did and did not undergo revascularization.
Eur. HJ 2008, 29, 1275
Death MI Stroke Triple endpoint
Re-admission for cardiac
illness
0
10
20
30
40
1.7 2.2 0.43.8
17
3.5 2.9 0.96.2
15
Revasc + Revasc -
Pat
ien
ts (
%)
P<0.0001P<0.01
P<0.0001
Death MI Stroke Triple endpoint
Re-admission for cardiac
illness
0
10
20
30
40
3 3.5 1.77
17
8.55.4
1.3
13
22
Revasc + Revasc -
Pat
ien
ts (
%)
P<0.0001 P<0.01
P<0.0001
Six-month post-discharge outcomes in elderly age groups according to those who did and did not
undergo revascularization.
Eur. HJ 2008, 29, 1275
Death MI Stroke Triple endpoint
Re-admission for cardiac
illness
0
10
20
30
40
125.2
2.2
1723
19
8.13.1
25 26
Revasc + Revasc -
P<0.0001 P=0.03
P<0.0001
Pat
ien
ts (
%)
Six-month post-discharge outcomes in very elderly age groups according to those who did and did not
undergo revascularization.
Eur. HJ 2008, 29, 1275
Optimal Medical Therapy With or Without Percutaneous Coronary Intervention in Older
Patients With Stable Coronary Disease
A Pre-Specified Subset Analysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive drug
Evaluation) Trial
• Koon K. Teo, MB, BCh, PhD*, Steven P. Sedlis, MD, William E. Boden, MD,*,
Robert A. O'Rourke, MD, David J. Maron, MD||, Pamela M.Hartigan, PhD¶, Marcin
• Dada, MD#, Vipul Gupta, MBBS, MPH, John A. Spertus, MD, MPH**, William J.Kostuk, MD, Daniel S. Berman, MD, Leslee J. Shaw, PhD, Bernard R.Chaitman,
MD||||, G.B. John Mancini, MD¶¶, William S. Weintraub, MD## COURAGE Trial Investigators
JACC 2009, 54, 1303
Primary and Secondary Outcomes by Treatment Arm and Age Group
Age <65 Yrs (n = 1,381)
OutcomeOMT
(n = 693) PCI
(n = 688) HR
(95% CI) p Value
Death 41 (6%) 25 (4%) 0.68 (0.42–1.10) 0.11
MI 76 (11%) 83 (12%) 1.12 (0.82–1.53) 0.44
Death/MI 110 (16%) 109 (16%) 1.01 (0.78–1.31) 0.93
Death/MI/stroke 115 (17%) 115 (17%) 1.02 (0.79–1.33) 0.86
ACS 85 (12%) 87 (13%) 1.03 (0.77–1.39) 0.83
COURAGE TRIAL
JACC 2009, 54, 1303
Primary and Secondary Outcomes by Treatment Arm and Age Group
Age >65 Yrs (n = 904)
OutcomeOMT
(n = 444) PCI
(n = 460) HR
(95% CI) p ValueInteraction
p Value
Death 54 (12%) 57 (12%) 1.01 (0.69–1.46) 0.97 0.21
MI 52 (12%) 60 (13%) 1.14 (0.79–1.66) 0.48 0.95
Death/MI 93 (21%) 104 (23%) 1.10 (0.83–1.45) 0.51 0.66
Death/MI/stroke 99 (22%) 109 (24%) 1.08 (0.82–1.42) 0.58 0.77
ACS 40 (9%) 49 (11%) 1.19 (0.79–1.81) 0.41 0.58
COURAGE TRIAL
JACC 2009, 54, 1303
Survival of Elderly Patients Undergoing Percutaneous
Coronary Intervention for Acute Myocardial Infarction Complicated by
Cardiogenic Shock
Han S. Lim, MBBS*,**, Omar Farouque, MBBS, FRACP, PhD, FACC*,, Nick Andrianopoulos, MBBS, MBiostat, Bryan P. Yan, MBBS, FRACP,, Chris C.S. Lim,
MBBS||, Angela L. Brennan, RN, CCRN, Chris M. Reid, BA, MSc, DipEd, PhD, Melanie Freeman, MBBS*, Kerrie Charter, RN, CCRN*, Alexander Black, MBBS, FRACP,,¶, Gishel New, MBBS, FRACP, PhD, FACC||, Andrew E. Ajani, MBBS, FRACP, FJFICM,
MD,,, Stephen J. Duffy, MBBS, MRCP, FRACP, PhD#, David J. Clark, MBBS, FRACP*,* on behalf of the Melbourne Interventional Group
JACC Intv. 2009, 2, 146
Clinical Outcomes : In-Hospital
Age ≥ 75 Years Age <75 Years p Value
In-hospital (n = 143) Mortality 19 (42.2) 33 (33.7 0.33
Complications
Periprocedural MI 2 (4.7) 2 (2.1) 0.41
Emergency PCI 1 (2.3) 1 (1.0) 0.53
Unplanned CABG 1 (2.3) 4 (4.3) 1.00
Bleeding 4 (8.9) 3 (3.1) 0.21
Congestive heart failure 18 (40.0) 25 (25.5) 0.08
Renal failure 13 (28.9) 12 (12.2) 0.02
Stroke 1 (2.2) 2 (2.0) 1.00
JACC Intv. 2009, 2, 146
Clinical Outcomes : 30 Days
Age ≥ 75 Years Age <75 Years p Value
30 days (n = 141)Mortality 19 (43.2) 35 (36.1) 0.42
MI 2 (4.5) 3 (3.1) 0.65
TVR 2 (4.5) 6 (6.2) 0.70
MACE 22 (50.0) 40 (41.2) 0.33
JACC Intv. 2009, 2, 146
Clinical Outcomes : One year
Age ≥ 75 Years Age <75 Years p Value
1 year (n = 117) Mortality 20 (52.6) 37 (46.8) 0.56 Cardiac 17 (85.0) 34 (91.9) 0.65
Noncardiac 3 (15.0) 3 (8.1) 0.65
MI 2 (5.3) 3 (3.8) 0.66
TLR 3 (7.9) 5 (6.3) 0.71
TVR 3 (7.9) 6 (7.6) 0.96
MACE 24 (63.2) 42 (53.2) 0.31
JACC Intv. 2009, 2, 146
Kaplan-Meier Estimates of Cumulative 1-Year Survival
JACC Intv. 2009, 2, 146
PCI IN AMI SHOCK
Kaplan-Meier Estimates of Cumulative 1-Year Freedom From MACE
JACC Intv. 2009, 2, 146
PCI IN AMI SHOCK
PCI IN AMI SHOCK
Multivariate Analysis of In-Hospital Mortality
Variable Odds Ratio 95% CI p Value
Renal failure 3.41 1.21–9.63 0.02
IABP use 2.11 0.97–4.59 0.06
STEMI 0.55 0.22–1.38 0.20
Diabetes 1.63 0.70–3.76 0.26
Hypertension 1.59 0.69–3.63 0.27
Age ≥ 75 years 1.04 0.46–2.36 0.93
JACC Intv. 2009, 2, 146
Long-Term Paclitaxel-Eluting Stent Outcomes in Elderly Patients
Daniel E. Forman, MD; David A. Cox, MD; Stephen G. Ellis, MD; John M. Lasala, MD; John A. Ormiston, MD; Gregg W. Stone, MD;
Mark A. Turco, MD; Jeanne Y. Wei, MD; Anita A. Joshi, MD;Keith D. Dawkins, MD and Donald S. Baim, MD
Circ Card. Vasc. Intv. 2009 2, 178
5-year cumulative rates of death (upper left), MI (upper right), Academic Research Consortium, definite/probable ST (lower left), and TLR
(lower right) for patients receiving PES in the randomized trials
Circ. Card. Vasc. Intv. 2009 2, 178
5-year cumulative rates of death (upper left), MI (upper right), Academic Research Consortium, definite/probable ST (lower left), and target lesion revascularization (TLR) (lower
right) for PES versus BMS in patients aged >70 years in the randomized trials
Circ. Card. Vasc. Intv. 2009 2, 178
TAKE HOME MESSAGE
PCI results in elderly are comparable with younger population
due to improved tech. Hardware and des
The results of PCI including multi site arterial involvement
have become acceptable
Number of elderly is growing due to improved longevity
Thank you!!