Journal of Invasive Cardiology

The elderly patient with coronary artery disease (CAD) poses unique challenges in clinical management. The basic problem is that there are insufficient data from dedicated clinical trials to provide a framework for decision making. Clinical decisions in elderly patients are thus mainly empiric. The proportion of elderly patients who are included in randomized revascularization trials is much lower than the actual percentage in the CAD population as a whole.¹ Elderly patients in registries and large series exhibit the greatest benefit from interventional procedures when compared to patients in the general population, but they also run the highest risk of complications. Consequently, the younger age groups are preferentially revascularized in clinical practice, a paradoxical utilization of resources in a population that derive the least demonstrable benefit.²
Percutaneous coronary intervention (PCI) is less invasive than coronary artery bypass graft surgery (CABG) and requires a shorter recovery time. Such benefits would appear to be particularly advantageous in the elderly, especially those with coexisting noncardiac disorders that may pose significant additional operative risk. Conversely, the limited expected lifespans render conclusions concerning long-term benefits dependent on many extraneous factors besides treatment effect. Despite the fact that over 50% of all PCIs in the United States are performed in patients older than 65, the basic medical tenet to “first do no harm” leads to conflicting philosophical approaches. Further, since clinical trials of new therapies frequently exclude this age group, any conclusion about the efficacy of new techniques are inferential or based on observational data from registries and small series. Additionally, many randomized trials of PCI in various clinical settings have a bias in case selection, either specifically or indirectly excluding elderly patients. This bias may be particularly prominent in some studies that have a defined upper age limit for randomization, but may also be present due to exclusions when certain high-risk factors found in a high percentage of elderly patients are prespecified.
Physicians therefore must rely on clinical judgment to choose which elderly patients should undergo invasive procedures, and cannot depend on a complete evidence base to assist in reaching decisions. There are at least six different characteristics the physician should assess in reaching this decision: (1) mental status (i.e., dementia versus mentally active); (2) emotional status (i.e., the patient wants to live as long as possible versus a readiness to die); (3) independence (i.e., the patient lives alone versus being incompetent); (4) physical activity (i.e., immobile or bedridden versus a vigorous lifestyle); (5) compliance with medications; and (6) comprehension, by both patient and family, of the potential benefits and risks of a revascularization procedure.