Percutaneous Coronary Intervention in the Elderly Patient (Part I of II)
- Volume 18 - Issue 6 - June, 2006
- Posted on: 8/1/08
- 0 Comments
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Although coronary stents have improved clinical outcomes, registry data continue to demonstrate worse outcomes than in age-matched controls.6–9,14–16 Such observations have led some to question the value of aggressive PCI strategies in elderly patients.11,17 The relative survival rates of PCI versus CABG versus medical therapy in similar patient types from a single, large center or registry have not been definitively assessed in the contemporary stent era. Recently, a randomized trial of invasive versus medical therapy in the elderly found that patients older than 75 years of age benefit more from revascularization than from optimized medical therapy. Both symptom relief and quality of life were enhanced in patients undergoing PCI. However, this is a small trial with only six-month follow up.18
Conversely, Tu et al.20 evaluated the use of cardiac procedures and outcomes in elderly patients in the United States and in Canada. The authors found that U.S. patients were more likely than Canadian patients to undergo coronary angiography (34.9% versus 6.7%; p < .001) and PCI (11.7% versus 1.5%) during the first 30 days after myocardial infarction. Interestingly, the 30-day mortality rates were slightly, but significantly, lower for U.S. patients than for Canadian patients (21.4% versus 22.3%; p = 0.03). However, the one-year mortality rates were virtually identical (34.3% United States versus 34.4% Canada; p = 0.94).
The Alberta Provincial Project for Outcome Assessment and Coronary Heart Disease Study21 is a Canadian study demonstrating that elderly patients experience the largest absolute risk reductions associated with CABG or PCI compared to younger patients. Adjusted four-year survival rates in CABG and PCI patients were compared to medical therapy. The data demonstrated that the largest absolute risk reduction associated with revascularization was observed in the oldest patients. Additionally, the elderly also experienced the highest medical- and revascularization-associated mortality rates of any age group. These findings are important in illustrating the benefits of an aggressive revascularization strategy in elderly patients.
Seto et al.22 showed that quality of life improvements after PCI are not age-dependent. These authors evaluated the medical outcomes in a study using the Short Form Survey and Seattle Angina Questionnaire in a group of 295 patients over the age of 70 and 1,150 younger patients. At six months, physical health had improved in 51% of elderly patients, and mental health had improved in 29% of patients undergoing PCI. The authors found that the probability of clinically meaningful improvement in lifestyle following PCI was not significantly associated with age; elderly patients are just as likely to experience improved enjoyment in their life as younger patients after PCI. That post-PCI survival, but not quality of life, is age-dependent is a crucial observation, and is an important consideration in patient selection. Physical and mental health improvements are very important to the elderly. Especially as patients get older, it is reasonable that their goal may be to live better rather than longer.