By Michael Crawford, MD, Editor
Professor of Medicine, Chief of Clinical Cardiology, University of California, San Francisco
Dr. Crawford reports no financial relationships relevant to this field of study.
SYNOPSIS: Nonagenarians can undergo percutaneous coronary interventions with low in-lab complication rates, but 30-day and one-year mortality is considerably higher than in younger patients.
SOURCES: Sawant AC, Josey K, Plomondon ME, et al. Temporal trends, complications, and predictors of outcomes among nonagenarians undergoing percutaneous coronary intervention: Insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking program. JACC Cardiovasc Interv 2017;10:1295-1303.
Holmes DR Jr. Four score and 10 years. JACC Cardiovasc Interv 2017;10:1304-1306.
As longevity increases, more patients ≥ 90 years of age are presenting for percutaneous coronary interventions (PCI), especially since coronary bypass surgery is less attractive in these patients. However, there are little data in clinical trials concerning this age group. Investigators used the national database of the Veterans Affairs (VA) Clinical Assessment, Reporting and Tracking (CART) program to determine the prevalence of nonagenarians undergoing PCI between 2005-2014, and their clinical characteristics and PCI complications, compared to younger patients. CART identified 67,148 veterans who underwent PCI during these 10 years. The National Cardiovascular Data Registry (NCDR) Cath PCI score was evaluated for risk stratifying nonagenarians. Also, the authors used a multivariable frailty model to adjust the one-year mortality data. Any patients who died < 30 days after PCI were excluded from the one-year data. Of the 67,148 patients, 804 were nonagenarians (1.2%) and of these, 274 (34%) had PCI. Most of the patients were male (98%) and Caucasian (81%). Compared to younger veterans, the nonagenarians had a lower body mass index and were less likely to be smokers, diabetics, or have family history of coronary artery disease. They were more likely to suffer from hypertension, systolic heart failure, cardiovascular disease, and chronic kidney disease. They also were more likely to experience acute coronary syndrome, cardiogenic shock, or renal failure on presentation. After PCI, nonagenarians were more likely to develop acute cardiogenic shock (0.73% vs. 0.12%; P = 0.04) and no reflow (2.9% vs. 1%; P = 0.02). The 30-day post-PCI mortality was higher than in younger patients (10.6% vs. 1.4%; P < 0.0001) as was adjusted one-year mortality (16.2 vs. 4%; P < 0.0001). Also, the adjusted 30-day mortality hazard ratio (HR) was 2.14 (95% confidence interval [CI], 1.42-3.22) and one-year mortality HR was 1.82 (95% CI, 1.27-2.62). The NCDR Cath PCI risk score was highly predictive of both 30-day (HR, 2.29; 95% CI, 1.86-2.82) and one-year mortality (HR, 1.43; CI, 1.07-1.9). The authors concluded that nonagenarians are a small but growing proportion of PCI patients who experience worse outcomes, and the NCDR Cath PCI risk score is an excellent predictor of mortality in these patients.
As a general cardiologist, I have noticed an increasing number of nonagenarians presenting with acute coronary syndromes, usually non-ST elevation myocardial infarction, who potentially could benefit from PCI. Because of comorbidities, they often are not good candidates for bypass surgery. Family members, who often are enthusiastic about PCI, push their loved ones toward more aggressive management short of surgery. However, once coronary angiography reveals severe calcific three-vessel disease, our enthusiasm wanes, but we usually push on with the PCI. Unfortunately, the outcomes after PCI are not always good in this group, and we wonder if we did the right thing. When we go to the guidelines or the randomized trial data, we don’t find much to help us. Consequently, this study was of great interest to me.
This study confirmed my experience and observational reports that the number of nonagenarians presenting with coronary artery disease is increasing. The number of such patients doubled in this study between 2010 and 2014, and it confirmed that PCI can be performed with a low in-lab complication rate. They reported no myocardial infarctions, strokes, tamponade, or perforations in the lab. Also, they confirmed a higher mortality rate post-PCI but less than some studies have reported. This suggests that 21st century VA cardiac care is quite good. What is new about this report is the demonstration of the predictive ability of the NCDR Cath PCI risk equation, which uses the following variables: age, cardiogenic shock, heart failure, vascular disease, chronic lung disease, glomerular filtration rate, New York Heart Association class, and PCI characteristics to estimate mortality. In this study, the survival at 30 days and one year was particularly poor in the highest risk quartile of patients (score of 40-95 points). Also, none of the nonagenarians who presented in cardiogenic shock survived 30 days. Although the NCDR Cath PCI score should be tested prospectively, it gives clinicians some guidance on who is at highest risk and confirms the futility of PCI in nonagenarians who present in cardiogenic shock.
This study has limitations. One big one is that involves only those sent to PCI; there is no conservative therapy comparison group. Also, most nonagenarians are women, yet this is largely a study of men. There was little use of fractional flow reserve (< 4%), and we are not provided with coronary anatomic data. Despite these limitations, I believe this study will aid me in decision-making regarding nonagenarians presenting with coronary disease.