The outcomes of percutaneous coronary intervention (PCI) in nonagenarians is an understudied topic. A recent observational study published in the Journal of American College of Cardiology has looked into the time-dependent PCI trends and outcomes in 70,000 nonagenarians from 2003 to 2014 using data from the National Inpatient Sample, which is the largest longitudinal hospital inpatient database in the United States.
Trends throughout a decade
Nonagenarians represented 0.9% of all the patients hospitalized for PCI during the period from 2003 to 2014 (69,271 patients). However, their percentage increased from 0.6% in 2003-2004 to 1.4% in 2013-2014. It was also found that the percentage of PCIs performed for ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSEACS) significantly increased (23.1% to 30.9% and 49.6% to 52.6%, respectively) while the percentage of PCIs performed for stable ischemic heart disease (SIHD) significantly decreased (27.3% to 16.5%, ptrend <0.001 for all).
“This study is important because it demonstrates that there is no explicit (chronological) age cutoff above which older adults should not be offered PCI.” – Dr. Aditya Mandawat, M.D.
After adjusting for multiple confounders and comparing the patients from the mentioned time points, it was found that in-hospital mortality after PCI for SIHD increased (OR 1.21; 95% CI 1.01-1.44) while in-hospital mortality after PCI for STEMI and NSTEACS had no significant change. Bleeding and vascular complications after PCI decreased or did not change between 2004 to 2014 in patients with STEMI, NSTEACS and SIHD.
In the accompanying editorial, Dr. Aditya Mandawat (Duke University Hospital, Durham, North Carolina) and Dr. Anant Mandawat (Emory University Hospital, Atlanta, Georgia) commented, “The outcomes in nonagenarians were highly dependent upon initial presentation, with PCI for stable ischemic heart disease associated with the best outcomes, and PCI for ST-segment elevation myocardial infarction presentations associated with the worst outcomes.”
Outcomes stratified by indication
The authors claimed that this was the “first study to date presenting outcomes and trends of PCI stratified by indication in a nationally representative cohort.” The indications were: STEMI, NSTEACS, and SIHD. For patients with STEMI, it was found that only 10.7% of them had PCI despite the fact that performing PCI was associated with a 65% lower odds ratio of in-hospital mortality. The proportion of patients complicated with cardiogenic shock after PCI due to STEMI showed an increasing trend (9.9% vs 18.8%). This indicated the trend of performing PCI in patients with higher risk.
NSTEACS represented the most common indication of PCI in this cohort. However, only 5.6% of patients with NSTEACS had undergone PCI. Similar to patients with STEMI, invasive management was associated with lower odds of mortality. Other outcomes such as in-hospital mortality, major bleeding, and stroke did not change significantly. The authors suggested that the use of invasive strategies for the management of acute coronary syndrome in nonagenarians was clearly underused and should be considered more in this patient population. It was also observed that in-hospital mortality after PCI in SIHD patients had a significant increase from 2003 to 2014 (1.2% vs 3.9%).
It is already known that older patients have more complex lesions and coronary calcifications but the reason for the increased in-hospital mortality is not fully understood, and more data about the lesion types and left ventricular function will be needed. Dr. Mandawat comments that the study “does not provide additional insight into whether PCI is superior to optimal medical therapy in these patients as the analysis is retrospective and from an administrative dataset.” “At best, all that can be said is that highly selected nonagenarians who are referred for PCI have better outcomes than non-selected nonagenarians who receive (perhaps nonoptimal) medical therapy,” they add.
The investigators conclude, “This study is important because it demonstrates that there is no explicit (chronological) age cutoff above which older adults should not be offered PCI.”