Predictors of hospital mortality in the elderly undergoing percutaneous coronary intervention for acute coronary syndromes and stable angina

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Abstract

Background

The percentage of elderly treated with percutaneous coronary intervention (PCI) has been increasing year by year. Little is known about predictors of hospital mortality in elderly undergoing PCI for acute coronary syndromes (ACS) and stable angina.

Methods

Between 2005 and 2008 a total of 47,407 consecutive patients undergoing PCI were prospectively enrolled into the PCI-Registry of the EHS Programme. For the present analysis patients were divided into four categories: ACS patients ≥ 75 (n = 4,943) and < 75 years (n = 19,446), and patients with stable angina ≥ 75 (n = 3,393) and < 75 years (n = 19,625). A multiple logistic regression analysis was conducted to detect independent predictors of mortality in patients 75 years undergoing PCI. In addition, differences in clinical characteristics, procedural details and in-hospital outcomes between the subgroups were evaluated.

Results

Patients ≥ 75 years had more co-morbidities, and more severe coronary pathology. The use of guideline-recommended adjunctive therapy and procedural success was high in all groups. The incidence of in-hospital death was highest in ACS patients ≥ 75 years (5.2%) and < 75 years (1.7%), followed by patients with stable angina ≥ 75 (0.5%) and < 75 years (0.2%). Haemodynamic instability and acute ST-elevation myocardial infarction were the strongest determinants of hospital mortality among patients ≥ 75 years with ACS, whereas interventional complications were the most meaningful predictors of death in older patients undergoing elective PCI.

Conclusions

Patients ≥ 75 years undergoing PCI face a relatively low risk of hospital death. However, complication rates were significantly higher compared to younger patients, strongly influenced by clinical, angiographic and interventional variables.

Introduction

New methods for prevention and treatment of cardiovascular diseases have improved outcomes and increased life expectancy. An increasing number of elderly patients therefore require subsequent medical and interventional therapy. This is a challenge for modern cardiology since past documentation of clinical practice indicates that the management of elderly patients often differs from that of younger patients [1], [2], [3], [4], [5], [6]. Furthermore, elderly cardiac patients, particularly those with severe co-morbidities, have been underrepresented in randomized clinical trials relative to their disease prevalence [7].

Elderly undergoing PCI are at higher risk for complications compared to younger patients, emphazising the growing importance of investigating periprocedural modalities and prognostic factors [8], [9], [10]. In the past determinants of mortality have been investigated in elderly patients undergoing PCI [8], [10]. However, angiographic and procedural variables were not incorporated in these analyses.

Within the large Euro Heart Survey PCI Registry, which enrolled patients from 2005 until 2008, the current practice in patients of two age groups (≥ 75 and < 75 years) with and without ACS was compared. For the first time preprocedural, angiographic and interventional factors predictive of mortality in patients ≥ 75 years undergoing PCI were determined. In contrast to previous investigations patients with ACS and stable angina were analyzed separately.

Section snippets

The PCI-Registry of the Euro Heart Survey Programme

The PCI-Registry is a prospective, multi-centre, observational study on current practice of unselected patients undergoing elective or emergency PCI. Consecutive patients with ACS or stable coronary artery disease (CAD) were recruited within the period from May 2005 to April 2008. The participating hospitals were located throughout Europe (176 centres in 33 ESC countries) and included university hospitals, community hospitals, specialist cardiology centres and private hospitals all providing

Baseline characteristics

For the present analysis patients were divided into four categories: ACS patients ≥ 75 (n = 4943, 10.4%) and < 75 years (n = 19,446, 41.0%), and patients with stable angina ≥ 75 (n = 3393, 7.2%) and < 75 years (n = 19,625, 41.4%). The baseline characteristics of the patients are shown in Table 1.

The angiographic and interventional characteristics

In the older group, coronary angiography revealed more severe CAD as compared with the younger patients. The elderly more often underwent PCI of left main stem and bypass grafts. There were no major age-related

Discussion

This analysis of the PCI-Registry of the Euro Heart Survey Programme with more than 47,000 patients including over 8000 patients ≥ 75 years gives a consistent overview of contemporary PCI practice. The data show that among this age group PCI can be performed with a relatively low rate of hospital complications. However, patients aged ≥ 75 years with coronary artery disease face a significantly higher risk for in-hospital death, mainly due to a higher prevalence of co-morbidities and a more severe

Limitations

The present analysis is not a randomized, controlled study. In the EHS PCI registry the treatment was left to the discretion of the physician. This may lead to a bias in the estimation of treatment effects, which cannot be fully eliminated even by using a multivariate analysis. Only patients undergoing PCI were enrolled into the registry which might reflect a selection bias towards the more fit elderly which had been considered for interventional treatment by the treating physician.

The EHS PCI

Conclusions

The risk of adverse events among patients ≥ 75 years undergoing PCI is relatively low. This is probably due to advances in PCI-technique, operator ability and guideline-adherent adjunctive medical treatment. Nevertheless, complication rate is significantly higher than in younger patients. Among patients ≥ 75 years with ACS the most meaningful mortality predictors were haemodynamic instability and acute STEMI, followed by acute segment closure. Co-morbidities and severe coronary pathology also

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [19].

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    Similar results were seen for stable angina (0.5% vs 0.2%; P < 0.001). Independent predictors of in-hospital mortality were hemodynamic instability and ST-elevation MI in the ACS group, and procedural complications in the stable angina group.45 Other independent predictors of mortality have been identified, such as ejection fraction < 35%, renal insufficiency, and diabetes.46

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ESC Board Committee for the Euro Heart Survey Programme 2006–2008: Anselm K. Gitt (Chairperson) (Germany), Hector Bueno (Spain), Nicolas Danchin (France), Kevin Fox (UK), Peter Kearney (Ireland), Aldo Maggioni (Italy), Keith McGregor (France), Gregorsz Opolski (Poland), Ricardo Seabra-Gomes (Portugal), Franz Weidinger (Austria).

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