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DOI: 10.20517/2574-1209.2018.29 Vessel Plus
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Percutaneous coronary intervention in the elderly:
current updates and trends
Mohammed J. Arisha1, Dina A . Ibrahim2, Ahmed A. Abouarab3, Mohamed Rahouma3, Mohamed K. Kamel3,
Massimo Baudo3, Kritika Mehta3, Mario F. L. Gaudino3
1Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL 35233, USA .
2Department of Medicine, Brown University, Providence, RI 01912, USA.
3Department of Cardiothoracic Surgery, Weill Cornell/New York Presbyterian Hospital, New York, NY 10065, USA.
Correspondence to: Dr. Mario F. L. Gaudino, Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th St.,
Suite M 404, New York, NY 10065, USA. E-mail: mfg9004@med.cornell.edu
How to cite this article: Arisha MJ, Ibrahim DA, Abouarab AA , Rahouma M, Kamel MK, Baudo M, Mehta K, Gaudino MFL.
Percutaneous coronary intervention in the elderly: current updates and trends.
Vessel Plus
2018;2:14.
http://dx.doi.org/10.20517/2574-1209.2018.29
Received:
8 May 2018
Accepted:
5 Jul 2018
Published: 9
Jul
2018
Science Editors: Aaron S. Dumont, Alexander D. Verin Copy Editor: Jun-Yao Li Production Editor: Cai-Hong Wang
Abstract
Ischemic heart disease is the leading cause of death with acute coronary syndrome accounting for more than 30% of
causes of mor tality in the elderly population. The rate of growth of the older segment of the population has increased
exponentially and will become more pronounced in the future. Historically, there has been a paucity of clinical trials
investigating the challenges and outcomes of more invasive treatment strategies such as percutaneous coronary
intervention (PCI) for that very segment of the population. However, the safety, efficacy, and outcomes of PCI in the
older population have started to receive more attention, leading to some changes in their trends. There are several
factors that make interventional cardiologists more resistant to direct the elderly to PCI. Most of these challenging
factors, such as the complexity of coronary lesions, frailty, hematological and vascular changes, are discussed in this
review. In addition. more advanced technologies have been introduced to PCI platform such as second- and third-
generations stents, several alternative approaches have been adopted like transradial approach and the usage of
bivalirudin instead of heparin and GP IIb/IIIa inhibitor, and several imaging modalities have been optimized to assess
patients’ outcome and prognosis more accurately. Several recent studies have shown better results when these
strategies are adopted. The most recent recommendations regarding performing PCI in the elderly are also discussed in
this review.
Keywords
: Percutaneous coronary intervention, coronary artery disease, acute coronary syndrome, coronary stents,
angioplasty, elderly, old age patients, frail patients, high risk patients
INTRODUCTION
Ischemic heart disease is one of the major challenges that encounter healthcare providers all over the world.
It is considered the leading cause of death with acute coronary syndrome (ACS) accounting for more than
30% of causes of mortality in the elderly population (aged 65 years or older)[1]. e elderly group of population
has grown substantially. For many reasons, the rate of growth has increased exponentially and will become
more pronounced in the future, especially in the developed world. In 1970, the population aged 65 years and
older constituted only 9.8% of the total population in the United States, however, in 2012 it increased to 13.7%
and it is expected to exceed 20% by the year 2030. Octogenarians and older populations constituted a smaller
segment of only 3.7% comparing to their younger counterparts in 2012 but it is also expected to jump up to
3.9% and 5.4% by 2020 and 2030, respectively[2]. Despite the recent advancements that have been achieved
in both clinical and interventional cardiology realms, the management of coronary artery disease (CAD) in
the elderly is still a major concern, both for cardiac interventionists and surgeons. Historically, older patients
oen receive conservative management rather than invasive procedures and there is a paucity of clinical
trials investigating the challenges and outcomes of more invasive treatment strategies for that very segment
of the population. erefore, this relative under-representation of elderly in clinical trials and the consequent
lack of knowledge made many cardiology interventionists more reluctant to perform percutaneous coronary
intervention (PCI) for very elderly patients which hinders their optimal evidence-based therapy[3]. Recently,
safety and outcomes of PCI in the older population has started to receive more attention, therefore, changes
in its trends have to be studied thoroughly. In this review, we discuss age and its impact on older patients’
stratication and prognosis, the most relevant challenges that make PCI more dicult in this group of
patients, recent changes in trends of PCI in the elderly, and the latest guidelines and recommendations.
AGE AND PCI
ere is no specic age beyond which PCI cannot be performed, however, with increasing age less
invasive therapy is usually preferred. In the literature, even a few centenarians underwent successful PCI
procedures[4,5]. e oldest reported case was a 106-year-old lady who presented with inferior wall ST-segment
elevation acute myocardial infarction (STEMI)[5] . It is also dicult to assign a clear-cut age threshold to
classify patients based on their ages as risky vs. non-risky patients. However, according to the data from the
Global Registry of Acute Coronary Events (GRACE), patients aged 75 years or more had more cardiovascular
risk factors such as history of congestive heart failure (CHF), myocardial infarction (MI), hypertension,
atrial brillation, diabetes mellitus, and stroke comparing to younger patients[3]. Also, patients aged 75 years
and older were considered a special group in the American College of Cardiology Foundation/American
Heart Association (ACCF/AHA) guidelines[6,7]. us, in this review, we dene risky old patients as patients
aged 75 or more.
Age of patients presenting with ACS has a signicant prognostic value and it is considered the second most
important predictor of mortality aer Killip class as it has been shown that the in-hospital mortality risk of
a patient with ACS increases by 1.7 fold for each 10 years and by 2 folds for each Killip class deterioration[8].
Risk stratication plays a crucial and decisive rule during the initial management of ACS patients, as it
helps to determine the appropriate site of care and the intensity of therapy. Age among other patients’
demographic characteristics profoundly aects this stratication as well as the initial estimate of death and/
or other cardiac events even before performing any physical examination or reviewing electrocardiograms
(ECG) and laboratory results[6]. is is why, age is usually a vital criterion in several scoring systems that are
used to estimate the in-hospital, 30 days, and even 1-year mortality rates of patients presenting with ACS
and risk of complications as well. Among these scoring systems, the GRACE risk score[9,10], the thrombolysis
in myocardial infarction (TIMI) risk score[11,1 2], and the “platelet IIb/IIIa in unstable angina: receptor
suppression using integrilin therapy” (PURSUIT) risk score[13]. According to the GRACE score, age of more
than 75 adds a mortality risk score of 73. For TIMI score, age of more than 65 adds a 5% risk at 14 days of:
all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.
Page 2 of 17 Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29
As far as the PURSUIT score, age of 70 or more adds a mortality only risk of 4 points and a risk of mortality
and infarction of 11 points.
PCI CHALLENGES IN OLDER POPULATION
Providing proper management and rehabilitation for older patients could be very challenging. Certainly,
this becomes more sophisticated if a more invasive procedure such as PCI is required. Factors that make
interventional cardiologists more resistant to perform PCI for an elderly patient can be either general factors
related to the patient’s general status such as frailty, co-morbidities, functionalities of their cardiovascular
and other systems or local factors related to coronary lesions such as the complexity of these lesions. Here,
we discuss the most relevant factors in more details.
FRAILTY AND MULTI-MORBIDITY
Frailty is oen dened as gradual insuciency and regress of multiple body systems that eventually lead to
an ultimate state of low reserve, functional/ cognitive decline, and inability to cope with dierent stressors.
It is also considered by geriatricians to be a clinical syndrome that makes patients vulnerable to a variety
of adverse outcomes[14]. Frailty becomes more apparent with aging, and unfortunately, even with the best
healthcare and interventions provided to the elderly in order to support, improve, and maintain their quality
of life, frailty is usually inevitable at a certain point of their age[15]. Based on the analysis of data from 4735
out of 5888 participants of the Cardiovascular Health Study (CHS), the mean ages of non-frail, intermediate
state, and frail patients were 71.5, 73.4, and 77.2 years, respectively. e same study demonstrated a higher
prevalence of cardiac risk factors such as CHF, history of angina, MI, peripheral vascular disease (PVD), and
carotid stenosis in frail patients[16] . Some inammatory markers such as C-reactive protein (CRP) and some
clotting factors like factor VIII and brinogen were found to be in higher levels in frail patients compared
to non-frail ones, suggesting that the high prevalence of some PCI adverse outcomes such as thrombotic
complications in the aging frail population can be explained by an inammatory process yet to be
understood[17] . With aging, a variety of cardiac and non-cardiac morbidities usually exist concurrently with
the patients’ coronary problems which makes it even more dicult for them to suit such procedures and to
overcome any ominous adverse event. In the United States, the prevalence of cardiac diseases, hypertension,
stroke, chronic obstructive pulmonary disease (COPD), kidney diseases, arthritis, and a lot of cancers is
higher among the population aged 75 and older more than any other age group[18] .
POLYPHARMACY
With the increased prevalence of dierent morbidities among older patients, being on multiple medications
at the same time is an expected consequence. Polypharmacy is more pronounced in the geriatric population
and it makes patients more prone to many cardiac events which makes deciding PCI for them more unlikely.
Data collected from 384 old frail patients participated in the Geriatric Evaluation and Management (GEM)
Drug Study revealed that more than 40% of the participants were on 5 to 8 dierent medications and more
than 37% had even more than 8 medications at the time of their discharge[19]. In a prospective cohort study
on old aged men with a mean age of 77 years, polypharmacy was associated with poor cardiovascular events
such as MI and stroke with a statistically signicant hazard ratio of 1.09 (95% CI: 1.06-1.12)[20]. In addition
to that, many factors associated with advanced age such as the decrease in renal function, low glomerular
ltration rate, decreased liver mass and blood ow can alter many drugs pharmacokinetics and reduce their
hepatic and renal elimination predisposing patients to more adverse events[21] . Another challenge that could
be faced during dealing with any elderly who needs PCI, is adjusting the dose of their cardiac medications
as changes in water-fat balance in their body composite aect drugs distribution and dosing to a signicant
extent. Older patients have a lower total body water that leads to a lower volume of distribution and a
higher serum level of water soluble medications such as digoxin that necessitate reduction of its loading
Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29 Page 3 of 17
dose. In contrary, relative increase in total body fat resulted from reduction of adipose-free body mass in
elderly people leads to increased volume of distribution of fat-soluble medications such as lidocaine and
prolongation of their half-life[21]. Another issue is that the recommended use of dual antiplatelet therapy
(DAPT) in the elderly PCI patients has many additional complications which may inuence the choice
of the stent and the mode of management of these patients, including; higher risk of bleeding, need for
concomitant warfarin therapy for atrial brillation, the increased likelihood of having future non-cardiac
surgery, and the increased risk of falls[13] . When added to therapy, anti-coagulants dosing is also altered
with advanced age. It has been shown that old age is usually associated with a lower warfarin maintenance
dose with patients aged 80 to 89 years usually requiring only half of a total weekly dose (TWD) of warfarin
compared to patients aged between 20 and 59 years[22].
HEMATOLOGICAL AND VASCULAR CHANGES
A lot of changes that occur with aging may cause the elderly to paradoxically experience hemorrhagic or
thrombotic complications aer PCI. Age is a signicant independent predictor of major bleeding in ACS
patients who had PCI and it is associated with higher in-hospital mortality rates[23] . Case fatality has been
shown to be more than 18% in patients who experienced any major bleeding following PCI while 5% in
patients without major bleeding[23]. Interestingly, thrombotic complications such as stent thrombosis and
restenosis occurred more frequently with advanced age as well. In a previous study, 47% of all patients
aged 75 years and older who had PCI with stenting experienced a 50% or more restenosis at the stent site
or adjacent to it compared to only 28% in younger patients. Also, older patients experienced more diuse
restenosis (1 cm or more in length) than their younger counterparts[24] . Increased risk of bleeding in elderly
can be explained by several hematological alterations such as higher level of tissue plasminogen activator
(t PA)[25], lower platelets aggregation[26], and the presence of more advanced and complicated vascular disease
with more local changes, more atherosclerosis and hypertension[23]. In contrary, older people have a higher
blood viscosity, higher activity of several coagulation factors, and a lower brinolytic activity as it has been
proven that plasminogen activator inhibitor (PAI-1) level increases with age[27, 28 ]. ese changes cause a
prothrombotic state in older patients that potentially increases risk of post-PCI thrombotic complications as
well. In addition, aging is associated with impairment of vascular structure and endothelial function caused
by several interacting histological and molecular alterations such as increased collagen content, smooth
muscle changes, and altered composition of the extracellular matrix of the arterial wall. is can lead to
a gradual decrease in elastic bers, arterial wall rigidity, and increased risk of atherosclerosis and arterial
thrombosis[28]. Many PCI-related vascular complications such as large hematomas in femoral regions,
pseudoaneurysms, and arteriovenous stulas have been also associated with advanced age[29]. Also, the
gradual impairment of endothelial cells function that occur with aging leads to lower production of nitric
oxide and prostacyclin which play an important role in promoting vasodilatation as well as preventing
platelets aggregation[2 8, 30].
CORONARY LESIONS COMPLEXITY
Older patients usually have more complex and advanced coronary lesions which make PCI procedures more
dicult with a higher risk of complications and a lower chance of procedure success. Batchelor et al.[31] compared
the angiographic characteristics of 7472 octogenarian patients with 102,236 younger others undergoing PCI.
Older patients had more le main coronary artery (LMCA) and proximal le anterior descending (LAD) lesions
than patients aged 79 and younger, 7.3% vs. 5.7% (P < 0.01) and 24% vs. 20% (P < 0.01), respectively. In a dierent
sample of patients, the angiographic characteristics based on the modied ACC/AHA criteria revealed that
863 out of 2551 (33.8%) patients aged less than 75 years had coronary lesions of type B1 or less, in contrast to
only 37 out of 137 (27%) patients aged 75 years or more (P = 0.002). On the other hand, lesion types B2 and
C were more prevalent in older than younger patients, 72% vs. 65% (P = 0.002), respectively[24]. Older patients
had a higher number of aected vessels as well, as 55% of patients aged 75 or more had 3 diseased coronary
Page 4 of 17 Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29
vessels compared to only 24% of younger patients (P = 0.0001). Also, 22% of older patients vs. 38% of their
younger counterpart had only 1 diseased vessel (P = 0.0001)[24]. e Synergy between Percutaneous Coronary
Intervention with TAXUS and Cardiac Surgery (SYNTAX) score has been used to predict clinical outcomes
in patients undergoing PCI especially those with LMCA lesions and/or multivessel coronary disease based
on their lesions complexity[32] . More recently, this scoring system has been integrated with some independent
clinical variables such as the patient’s age, creatinine serum level, and le ventricular ejection fraction
(LVEF) to obtain the clinical SYNTAX score (CSS)[33]. Both scoring systems have been shown to be valid
in risk stratication and early mortality prediction among older patients with ACS undergoing PCI. While
the SYNTAX score did not predict long-term clinical outcomes, the CSS was useful in predicting the 1-year
major adverse cardiac and cerebrovascular events, reecting the potentially signicant impact of the patient’s
clinical and demographic factors such as their ages on their clinical outcomes[34] . Previous studies have also
shown that age is signicantly associated with increased coronary artery calcium score[35,3 6]. Calcication of
the coronary system is associated with coronary artery disease (CAD) and coronary artery calcium content
is highly associated with increased cardiovascular events[36].
PCI ADVERSE EVENTS
As a result of the previously mentioned factors, PCI outcome is expected to be worse in the older patients
comparing to the general population. Indeed, the most devastating outcome would be death. Although
studies have demonstrated reasonable short and long-term PCI outcomes in the elderly, the in-hospital,
30 days, and even 1 to 5 years follow-up all-cause mortality rates are still higher[37-39]. Aside from death,
there is a higher chance that older frail patients experience a variety of complications that can occur
consequently as a result of this procedure and aect patients’ clinical outcome and quality of life than other
younger patients[40]. Many cardiac complications have been described such as cardiogenic shock, acute MI,
acute ventricular septal rupture (VSR), iatrogenic coronary dissection, coronary perforation, and stent
thrombosis. Other non-cardiac complications have also been reported such as hemorrhage, acute kidney
injury, stroke, and access site complications like femoral or radial dissection and/or hematoma[41,42 ]. Major
bleeding is one of the complications associated with unfavorable clinical outcome. Pooled data from 5
dierent trials that participated in the RESOLUTE study program and included 5130 patients undergoing
PCI with the resolute zotarolimus-eluting stent showed that rates of some complications such as MI and
repeat revascularization in 1675 patients aged 70 years or older (33%) were similar to those of younger
participants, however, signicant bleeding events occurred more frequently among older population.
In-hospital and 1-month follow-up bleeding complications occurred in 1.3% and 1.6% of patients aged
70 years or older, and 0.3% and 0.5% of younger participants (P = 0.009 and 0.014), respectively. Death
occurred in 26% of old patients who experienced bleeding events with a median time of 21 days between
the bleeding event and time of death[38]. Another study showed an increase of 2.4% in over-all rates of
bleeding events among patients undergoing PCI in their octogenarian years than younger patients[37]. Many
dierent bleeding complications have been reported to be associated with PCI such as, access site bleeding,
pericardial bleeding that can lead to tamponade, retroperitoneal bleeding, and gastrointestinal bleeding
as well[37]. Beside age of the patient, many other variables have been proven to be an independent predictor
of unfavorable outcome in the elderly undergoing PCI. Reduced cardiac function with le ventricular
ejection fraction (LVEF) lower than 40%, Killip class of 3 or worse, cardiogenic shock, and hypotension
with systolic blood pressure (SBP) lower than 100 mmHg have all been identied as independent predictors
of an increased risk of 1-year mortality[43 ]. Also, the activity of daily living (ADL) of old age patients aer
PCI can be used to predict mortality. ADL assessment by Barthel index (BI) at the time of admission
and discharge has been investigated by Higuchi et al.[44] to predict 1-year mortality in very old patients
undergoing PCI for ACS. ey have shown that lower BI at the discharge of the patient can be a predictor
of higher mortality in patients aged 85 years and older with each 5 unites decrease in BI being associated
with 1.1 fold increase in 1-year mortality risk.
Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29 Page 5 of 17
Aside from this, the CHA2DS2VASc score[45] is a recognized predictor of the risk of having cerebrovascular
episodes. Patients aged 75 or more are assigned 2 on the scale, making the elderly patients more likely to
end up with higher scores. Adding the factor of gender, elderly females have a risk of 3 at baseline without
adding the risk attributed to the other comorbidities on the scale and the PCI procedure. Interestingly,
CHA2DS2VASc score of 2 or more was also found to be predictive of atrial brillation aer cardiac
procedures[46]. Table 1 summarizes the signicance of CHA2DS2VASc score in predicting stroke and atrial
brillation in the elderly population.
PCI TEMPORAL TRENDS
Historically, there have been a lot of variations in the reported data regarding procedure outcomes and
mortality rates among the older population undergoing PCI. Some of the papers published in the late eighties
through nineties showed the success rate of percutaneous transluminal coronary angioplasty (PTCA) in the
elderly to be approximately 82%-84% and highly variable mortality rates[47-4 9], however, Both success and
mortality rates have varied a lot in other papers published in the same era. Kern et al.[50] reported in 1988
a clinical success rate of a 67% in a group of 21 patients who had undergone PTCA in their octogenarian
years. Aer that, a clinical success rate of 57% was reported in 43 patients aged 75 years and older by other
investigators[51]. In contrary, Jeroudi et al.[52] demonstrated PTCA angiographic and clinical success in 50
and 49 patients, respectively out of 54 octogenarian patients (93% and 91%, respectively). Procedure success
has diered considerably between septuagenarians, octogenarians and older participants in the same group
of old aged patients as it was 85%, 73%, and as low as 50% for patients aged 70 to 74, 75 to 79, and 80 years
and older[49]. Also, procedural mortality rate varied and reached up to 19% during the same era[50 ,53]. Many
cardiac and non-cardiac complications were reported and occurred in more than third of the participants
in some of the previous studies[47,50 ]. Although PCI has been proven to be feasible in the older population,
the previous rates of success, procedural mortality, and consequent complications were unacceptable to
many healthcare providers which created a high level of prudence and caution before deciding to perform
PCI on such patients. Over years, several advanced technologies have been introduced, useful cardiac
imaging modalities have been more available, less invasive approaches and protocols have been investigated
to be adopted, and the operator techniques have been improved. As a result, a less conservative trend in
performing more invasive procedures on older patients has gradually appeared. In a cohort of 31,758 patients
who had undergone PCI between 2000 and 2007, the incidence of PCI in patients aged 75 and older has
increased from 56/100,000 in 2000 to 216/100,000 in 2007[54]. PCI share of older patients has increased even in
the very old segment such as the nonagenarians. Among 26,696 PCI performed over 11 years, only 177 were
performed on nonagenarians, however, the prevalence of PCI in this very subgroup of patients was 0.17% in
2004 and increased to 1.22% in 2014[41] . Recent studies have also shown some changes in PCI mortality and
complications trends. Generally, the success rate has improved, mortality and complications risk started to
approach those of younger population. In a very recent study that was published in 2018, the outcomes of
PCI in octogenarians and younger patients using second-generation cobalt-chromium everolimus-eluting
stents were practically the same[42] . Angiographic success was 98.4% in octogenarians and 98% in younger
participants (P = 0.85). A lot of both in-hospital and 1-year follow-up post PCI-complications were also
comparable between the 2 groups. In-hospital major bleeding events and cerebrovascular accidents have not
occurred in either of the 2 groups, however, acute kidney injury occurred more frequently in octogenarians,
Page 6 of 17 Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29
Table 1. Comparison of the predictive value of the CHA2DS2VASc score for stroke and atrial fibrillation in elderly patients
based on gender
Elderly >
75 years old
Baseline score
according to age
and gender only
Score after adding
a single additional
risk factor
Target high risk
score for atrial
fibrillation
Stroke risk (%) at
baseline score
Stroke risk (%)
after adding a
single additional
risk factor
Maximum
possible score
Male 2.0 3.0-4.0 3.0 2.2 3.2-4.0 8.0
Female 3.0 4.0-5.0 3.0 3.2 4.0-6.7 9.0
3.7% vs. 1.5% (P = 0.58). One-year follow-up myocardial infarction occurred in 1.9% and 1.5% (P = 1.00) in
octogenarians and younger patients, respectively. Interestingly, some complications occurred less frequently
with the octogenarian group than its younger counterpart such as in-hospital subacute stent thrombosis and
1-year follow-up cerebrovascular accidents, 0% vs. 1.5% (P = 1.00) and 1.9% vs. 2.3% (P = 1.00), respectively.
Although recent studies have also shown some variations in their results, in 2017 many papers have reported
relatively high PCI success rates in the elderly that ranged approximately from 75% to 95%[55-57]. Many of
these recent papers have reported better mortality and some complications trends than before[42,55,58,59].
Some of them even reported similar rates of major adverse events in both young adults and elderly in more
critical situations such as patients with atrial brillation (A-b) undergoing PCI. Lahtela et al.[60] conducted
a post-hoc analysis of 925 A-b patients’ data from the atrial brillation undergoing coronary artery stenting
(AFCAS) registry and showed comparable incidence of in-hospital and 1-month major adverse cardiac and
cerebrovascular events (MACCE) in octogenarian patients and younger ones[61]. It is worth mentioning that
some recent studies still demonstrate a quit high adverse outcomes rates including in-hospital mortality that
reached up to 20%[62,63].
PROCEDURAL ASPECTS IN ELDERLY
Many aspects regarding PCI procedure in the elderly can be modied, adjusted, and tailored in order to
make this very segment of the population more suitable for such a procedure and to render the interventional
cardiologists more comfortable to decide to perform these procedures in older patients. Among these aspects
are the length of procedure, the volume of contrast agent, the access site, the nature of the intervention, the
type of the stent, and the length of hospital stay.
ACCESS SITE
Generally, transfemoral approach has been the traditional standard of care for many years, however,
previous studies have shown that the newer transradial route is superior to the transfemoral one as the
former has been associated with better results and lower rates of complications and it has been increasingly
used instead of the femoral access in the general population[64,6 5]. In terms of the use of this approach in the
elderly undergoing PCI, the net benet is still not totally clear. e dierences between both approaches in
older patients have been reported in some studies and they demonstrated a high percentage of old patients’
PCI in whom transradial approaches have been performed. e transradial access has been used in up to
almost 80% of old aged patients of some cohorts[66,67]. In a 1:1 propensity score analysis of data from 1098
patients aged 75 years and older who underwent PCI with either transfemoral or transradial approach,
lower rates of in-hospital and 1-year follow-up major adverse clinical events, in-hospital MI, access site
complications, and major bleeding were associated with the use of transfemoral access[66]. Other adverse
clinical outcomes occurred less frequently with the transradial approach such as in-hospital death and
target vessel revascularization but there were no signicant statistical dierences between the two groups.
e same study demonstrated comparable rates of non-access site related major bleeding events with both
approaches[66]. In contrary, some recent studies have also shown a very low usage of the transradial approach
with the elderly. Among 1945 octogenarian patients of the Korea Acute Myocardial Infarction Registry,
1609 participants (82.7%) underwent PCI using the transfemoral approach and only 336 (17.3%) with the
transradial approach. Nevertheless, using the transradial access has been found to be a predictor of a lower
in-hospital mortality in the same group of patients[68]. In the same study, intra-aortic balloon pump (IABP)
had to be used in 103 (6.4%) patients in the transfemoral group vs. only 5 (1.5%) patients of the transradial
group. Access site can also aect other variables like the time and volume of the contrast agent and the
length of hospital stay, as the transradial approach was shown to be associated with a shorter hospital
stay and a lower dose of contrast dye comparing to transfemoral one among older patients[67]. However,
several other studies showed comparable contrast volume and procedure time with both approaches[41,6 6].
In terms of procedural success, several studies demonstrated almost similar PCI success in elderly using
Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29 Page 7 of 17
both approaches[41,68], however, many investigators believe that older population can benet more from the
transradial approach and it should be used more oen with the elderly undergoing PCI.
TYPE OF STENT
As it was discussed above, the coronary lesions in the elderly tend to be more complex and extensive which
may render them suitable only for plain old balloon angioplasty (POBA) due to a failure of stent delivery,
or inability to stent lesions in distal or small diameter vessels[4 3]. On the other hand, stenting technology
has revolutionized during the last era. Since their rst successful clinical application in 2002, drug-eluting
stents (DES) have been utilized more frequently comparing to bare metal stents (BMS) as lower rates of stent
restenosis, major adverse cardiac events, and revascularization of target lesions have all been associated with
the use of DES[69]. e second-generation DES even have a better stent design than the rst-generation ones with
a thinner strut and more biocompatible polymers which lead to a higher ecacy and lower complications[70,7 1].
However, the use DAPT for at least 1 year to prevent stent thrombosis associated with DES raises concerns
regarding increased risk of bleeding especially in populations with an already high risk of bleeding such as
the elderly[70]. Although some studies suggested reducing the DAPT to 3-6 months without an increase in the
risk of many adverse clinical events[72] . Recent data still suggesting under-utilization of DES in elderly patients
undergoing PCI with stenting[70 ]. e characteristics and clinical outcomes of 1564 high bleeding risk old
patients aged 75 years or older who participated in the LEADERS FREE trial and underwent PCI with the
deployment of either polymer-free DES or similar BMS and only 1 month of DAPT were analyzed[73 ,74] . ey
showed a high yet similar bleeding rate in the 2 groups. However, rates of mortality, stent thrombosis, MI, and
target lesion revascularization were lower in patients underwent stenting with DES reecting superior safety
and ecacy benets compared to BMS[74]. In addition to that, major bleeding rates did not dier signicantly
between octogenarian patients who received PCI with BMS and only 1-month mandatory DAPT and others
with DES and a 1-year course of DAPT in the XIMA trial[75]. Also, compared to the rst-generation DES, the
use of second-generation DES has been associated with better outcomes in the older population, as the latter
has been associated with a lower risk of MI in the following year among patients aged 70 years or older with a
hazard ratio of 0.40 (95% CI: 0.19-0.82); P = 0.012[58]. Most recently, the SENIOR trial demonstrated lower rates
of the 1-year all-cause mortality, MI, stroke, and revascularization in elderly patients who underwent PCI and
received third-generation DES with bioabsorbable polymer and a short-term DAPT compared to those who
received BMS[76]. In the same trial, the duration of DAPT was decided before patients’ random assignment to
the two dierent types of stents and it was recommended to be 1 month for stable patients and 6 months for
unstable ones, however, the bleeding complications were comparable in both study arms.
BLEEDING AVOIDANCE STRATEGIES
With peri-procedural bleeding being one of the most concerning topics regarding PCI in elderly patients[23],
several approaches and strategies have been developing aiming at reducing the amount of blood loss and
improving the safety and ecacy of these procedures in populations of high risk. Bleeding avoidance strategies
(BAS) include the usage of vascular closure devices (VCD), transradial approach instead of the transfemoral, and
bivalirudin instead of heparin and GP IIb/IIIa inhibitor[77]. Previous data showed that BAS have been associated
with lower risk of Peri-PCI bleeding, nevertheless, these strategies are underutilized among patients with higher
risk of bleeding suggesting what we call “risk-treatment paradox”[77,78]. Khambatta et al.[79] evaluated the data of
124,606 patients with dierent ages who underwent PCI over a period over 4 years to study the eect of BAS
on rates of bleeding and other variables in dierent age groups. ey have demonstrated a lower incidence of
bleeding with the utilization of BAS with an adjusted odds ratio of 0.982 (95% CI: 0.980-0.984) compared to
those without BAS usage in all age groups even patients older than 80 years. BAS was also associated with lower
in-hospital mortality with an adjusted odds ratio of 0.993 (95% CI: 0.992-0.994). Interestingly, although the
overall usage of BAS has been improving in all age groups over the whole study period, their utilization was
still less frequent in old age patients[79].
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TIME OF INTERVENTION
ere are some conicting data regarding the perfect timing of PCI in patients presenting with STEMI,
however, several previous studies have shown that shorter door-to-balloon time (DTBT) is associated
with better outcomes and many investigators believe that attempts to avoid any DTBT delay should be
adopted regardless the patient’s baseline risks[80,81]. Optimally, reperfusion should be attained within the
recommended 90-minute window, however, many patients still undergo PCI beyond this time limit[82].
DTBT has been shown to be longer among older populations compared to their younger counterparts in
several recent studies[57,6 2, 79]. e median DTBT in a cohort of 2972 consecutive patients who underwent
primary PCI for STEMI was 70, 76, and 80 min for patients aged < 75, 75 to 84, and ≥ 85 years, respectively
(P < 0 . 0 01)[57]. Being an old age patient per se, has been shown to be an independent predictor for the door-
to-balloon delay[83]. Other predictors have been described such as non-daytime presentation, the absence
of typical chest pain, the need for hospital transfer, female sex, and non-white race[83]. Elderly patients with
ACS oen present with non-specic and atypical symptoms like nausea, vomiting, diaphoresis, and dyspnea.
Chest pain occurs only in approximately 40% of patients older than 85 years[84]. Also, the higher prevalence
of le bundle branch block (LBBB) in older population patients makes the electrocardiographic diagnosis of
STEMI more dicult[8 4]. ese unusual presentations of ACS and time-wasting factors may cause some sort
of delayed diagnosis and management which consequently leads to worse outcomes in elderly undergoing
PCI that must be investigated thoroughly in the near future.
AUXILIARY CARDIAC IMAGING UTILIZATION
Over the last years, we have witnessed dramatic advancements in the eld of cardiac imaging. Several
imaging modalities such as transesophageal echocardiography (TEE), cardiac computed tomography (CT),
cardiac magnetic resonance imaging (CMR), and intravascular ultrasonography (IVUS) have been evolving
and their usefulness in the diagnosis and assessment of a variety of clinical and/or surgical situations has
been studied[85, 86]. We believe that the optimal utilization of several cardiac imaging modalities can provide
an additive benet to the patients undergoing PCI, especially among older populations. Moreover, the
integration of clinical and imaging data can assess patients’ prognosis and predict their clinical outcomes.
It also can dene and classify several procedural complications and guide healthcare providers to decide
whether to adopt a conservative management strategy or to proceed with more aggressive options[87]. For
instance, intra-operative TEE has been used to guide several procedures in the catheterization theater and
it provided useful assessments to some age-related PCI complications such as iatrogenic aortic intramural
hematomas and helped to assess the patient’s outcome and to decide the best management[87]. Furthermore,
with the latest developments of three-dimensional TEE, more accurate intra-operative images of stent
scaolds can be obtained which enabled some investigators to more condently diagnose and assess some
PCI complications like LMCA stent protrusion and migration[88,89] . us, and as we mentioned above, with
the older populations usually having more frequent LMCA lesions than younger patients, they can benet
from this modality. Also, IVUS and optical coherent tomography (OCT) have been shown to be useful in
the qualitative assessment and preparation of LMCA lesions and in stent sizing and optimization as well[90 ,9 1].
In addition to that, post-PCI risk stratication has been proven to be helpful in evaluating STEMI patients’
prognosis. e use of CMR during the hyperacute phase of STEMI aer primary PCI has been shown to be
safe and feasible[92]. Although the value of most of these imaging modalities in the elderly undergoing PCI as
a separate high-risk group has not been investigated in large scales studies, many of them may provide useful
contributions during the management of these patients in the future.
DIFFERENT INDICATIONS OF PCI IN ELDERLY
It has been shown that PCI was indicated for older population in a wide spectrum of dierent clinical
situations with variable disease severities, from primary PCI in unstable old patients with STEMI and urgent
PCI for those presenting with non-STEMI and unstable angina pectoris to elective PCI for old patients with
stable CAD. Many previous studies have demonstrated that older patients who underwent PCI for unstable
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Page 10 of 17 Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29
ACS constituted the bigger portion of the total elderly underwent PCI. Among 102 CAD patients aged 85 years
and older, PCI was indicated in an ACS setting in 72.6% of them and only 24.5% of PCIs were performed
for patients with stable angina[93]. In another cohort, 93% of 177 PCI performed on nonagenarians were
indicated in ACS settings and only 7% were elective PCI[41]. It is worth mentioning that clinical presentation
and PCI indication are considered signicant determinants of post-PCI clinical outcomes. As it has been
shown that short and long-term clinical outcomes are usually superior in older patients who underwent PCI
for stable CAD compared to unstable patients of the same age[93,94]. Among 102 PCI performed for a variety
of indications in very old patients, aged ≥ 85 years, there were 4 in-hospital deaths, all of them were patients
presented to PCI due to acute STEMI. However, there were no deaths among very old patients from the same
age group in whom PCI was indicated for stable coronary syndromes, post-STEMI, and other indications[93].
Teplits k y et al.[95] reported a zero percent cumulative mortality rate at 6-month aer elective PCI performed
for nonagenarian patients with stable CAD. e 6-month cumulative mortality rate in patients underwent
emergent PCI for clinically unstable ACS was 23% in the same study.
PCI AMONG OTHER REVASCULARIZATION AND REPERFUSION STRATEGIES IN ELDERLY
Generally, PCI is the most commonly used reperfusion strategy among all age groups[96]. In terms of
revascularization in older patients with CAD, a variety of strategies have been utilized, from conservative
management with no revascularization at all to the most invasive surgical revascularization. However, the
decision to choose the best reperfusion strategy for this high-risk group of patients has never been simple.
Peiyuan et al.[97] have compared the clinical outcomes of 3 groups of 3082 STEMI patients aged 75 years and
older. Reperfusion by PCI was performed in 1000 patients, brinolysis was administrated to 160 patients, and
the third group of 1922 patients did not have reperfusion therapy. PCI group had a signicant lower mortality
rates than brinolysis and no reperfusion groups of 7.7%, 15%, and 19.9%, respectively, P < 0.001. Several
adverse outcomes such as recurrent MI and MI-related complications like heart failure and cardiac arrest
occurred less frequently in PCI group. Other previous studies from dierent populations have demonstrated
better clinical outcomes in patients underwent PCI compared to those whom received brinolysis in all
age groups including the elderly[98,9 9]. A meta-analysis of 22 randomized trials that included 6763 patients,
also showed higher death and adverse outcomes rates of patients whom received brinolysis compared
to primary PCI group among all ages except patients aged 50 years and younger[99]. Another strategy that
involves combining brinolysis to urgent PCI can be potentially benecial for elderly patients with ACS. e
pre-hospital administration of a reduced-dose brinolytic agent before urgent PCI, termed FAST-PCI, showed
better 30-day mortality rates than primary PCI alone, 4.2% vs. 18.1%, respectively, P < 0.01 in STEMI patients
aged 75 years and older without an increase in rates of major bleeding events, stroke, or reinfarction[10 0].
Despite that many health care providers are still hesitant to direct old patients toward PCI, it has been shown
that with aging, the frequency of PCI increases and that of coronary artery bypass graing (CABG) decreases.
Nicolini et al.[101] compared the clinical outcomes and adverse events between PCI and CABG in a cohort of
patients aged 80 years and older with multivessel disease or LMCA lesions. PCI was performed in 947 patients,
while 441 underwent CABG. It is worth mentioning that, all nonagenarian patients included in the PCI group.
Although the 1-month mortality rates of both study arms were comparable, many adverse outcomes were
more frequent among patients who underwent PCI in the follow-up period such as cardiac mortality, MI, and
target vessel revascularization. In another larger cohort of 10,141 patients aged 85 years or older with ACS and
multivessel CAD, CABG was more frequently performed compared to PCI, and it was associated with better
survival and freedom from composite morbidity at 3 years follow-up[102]. us, it appears that CABG is still
the best strategy of revascularization in patients with multivessel disease or LMCA lesions even in elderly.
RECOMMENDATIONS
Several foundations and societies such as the ACCF, AHA, European Society of Cardiology (ESC), and the
Society for Cardiovascular Angiography and Interventions (SCAI) have tried to adopt some guidelines and
Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29 Page 11 of 17
recommendations based on the latest available clinical trials and observational studies in order to make the
decision of performing PCI on older patients clearer and more evidence-based. e management of older
population with CAD should be patient-centered and the decision whether to direct the patient toward
reperfusion therapy or to adopt a less invasive and more conservative management should not be taken
solely based on the patient’s age. On the other hand, the patient’s preferences, life expectancy, all his other
co-morbidities, and functional status should be considered before denying or recommending PCI. A report
from the ACCF, AHA, and SCAI stated that the PCI clinical benets in younger and older population are
comparable. However, the increased risk of some adverse outcomes in elderly like bleeding events and stroke
should be taken into consideration[103 ]. e latest ESC guidelines for management of patients presenting with
acute STEMI have also emphasized maintaining a high level of suspicion when dealing with any elderly
presenting with atypical symptoms to avoid any delay in the diagnosis and reperfusion therapy[104 ]. Primary
PCI should not have an upper age limit and any patient can be qualied for PCI based on his individual
circumstances. e transradial approach was also recommended whenever it is possible in these patients.
In addition, dosing of thrombolytic therapy should be adjusted carefully according to the patients’ kidney
function, other medications, and comorbidities. e ACCF and AHA have also recommended the use of
bivalirudin, instead of a GP IIb/IIIa inhibitor plus unfractionated heparin, both initially and at PCI in elderly
presenting with non-ST segment elevation ACS, as the former is associated with lower bleeding risks. However,
the dosing of all the medical therapy must be modied according to the patients’ body weight and creatinine
clearance[6]. ey have also stated that CABG can be preferred over PCI for appropriate candidates, especially
those with diabetes mellites and multivessel disease with SYNTAX score of more than 22 [Fig ure 1].
CONCLUSION
ere are several factors that render PCI a more challenging procedure among the elderly such as more
complex coronary lesions, co-morbidities, frailty, and hematological alterations. Historically, PCI clinical
outcomes have been demonstrated to be worse among older populations compared to their younger
counterparts. Moreover, the participation of the elderly in the clinical trials that investigated dierent aspects
of PCI has been markedly under-represented which created a vague state of decision making capability that
Figure 1. Summary of the 2014 AHA/ACC recommendations for the management of old patients ( 75 years of age) with non-ST-
elevation acute coronary syndromes. ACC: American College of Cardiology; AHA: American Heart Association; ACS: acute coronary
syndrome; CABG: coronary artery bypass graft; COR: class of recommendation; LOE: level of evidence; DM: diabetes mellitus; PCI:
percutaneous coronary intervention
Page 12 of 17 Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29
consequently could hinder the optimal t reatment for many old patients. Recently, more advanced technologies
have been introduced to interventional cardiology platforms, a variety of medical therapy options have been
available, less invasive PCI approaches have been adopted, more advanced cardiac imaging modalities have
been improving, and more attention to elderly undergoing PCI has been given. Although that PCI mortality
rates are still practically higher among the elderly, many recent studies demonstrated that PCI is safe and
eective for this segment of the population and some adverse clinical outcomes became similar to those
occurring in younger patients. us, the decision to perform PCI should not merely rely on the patient’s
age. Instead, many other considerations should be taken into account such as the patient’s functional and/
or cognitive status, preferences, co-morbidities, current medications, and life expectancy. In addition, more
elderly must be a part of the future clinical trials and the safety and ecacy of all the available as well as the
emerging less invasive PCI strategies have to be investigated more thoroughly in order to provide a clearer
knowledge regarding the optimal utilization of PCI among the elderly.
DECLARATIONS
Authors’ contributions
Design: Arisha MJ, Rahouma M, Baudo M
Organization of the manuscript: Rahouma M, Baudo M
Literature search: Arisha MJ, Ibrahim DA, Abouarab AA, Mehta K
Manuscript writing: Arisha MJ, Ibrahim DA, Abouarab AA, Kamel MK
Figures arrangement: Arisha MJ, Kamel MK
References arrangement: Mehta K
Read and approved the nal manuscript: Ibrahim DA, Rahouma M, Baudo M, Gaudino MFL
Availability of data and materials
Not applicable.
Financial support and sponsorship
None.
Conflicts of interest
All authors declare that there are no conicts of interest.
Ethical approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Copyright
© e Author(s) 2018.
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