pci in elderly patients

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!!