April 10, 2012
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DES May Be Preferable to BMS in Oldest Patients
Among patients aged at least 85 years who underwent PCI, use of
drug-eluting stents produced better outcomes compared with bare-metal stents,
including lower rates of mortality, despite an overall decline of DES use in
that age group.
The study included 471,006 patients from the CathPCI Registry of the
National Cardiovascular Data Registry who were at least 65 years of age and
underwent PCI between 2004 and 2008. These patients were matched to Medicare
fee-for-service data.
From 2005 to 2008, the population of patients at least 85 years of age
increased in both elective PCI (7% to 9%) and acute PCI (10% to 13%;
P<.001 for both) groups; however, researchers also reported that DES
use decreased with age.
Overall, use of DES was associated with lower rates of mortality in
those at least 85 years of age (adjusted HR=0.80; 95% CI, 0.77-0.83); age 75 to
84 years (adjusted HR=0.77; 95% CI, 0.75-0.79); and age 65 to 74 years
(adjusted HR= 0.73; 95% CI, 0.71-0.75). Risk of rehospitalization for MI was
also significantly lower among DES vs. BMS patients, with the greater risk
reported with increasing age (P<.001).
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Aravinda Nanjudappa, MD
This is an elegant study by Dr. Wang and colleagues. The results show
that a considerable number of PCIs are still being performed in the
octogenarian population of the United States. This is of concern for several
reasons irrespective of the use of DES or BMS:
- Octogenarians with CAD should be carefully accessed for management
of risk factors. PCI should be reserved for STEMI, patients with significant
ischemic burden by non-invasive testing after failed medical therapy, and
patients with recalcitrant angina despite medical therapy and unstable ACS.
- PCI in this subgroup as shown in the study will involve multivessel
PCI and, hence, risk of complications such as post-procedure cardiac enzyme
elevation and contrast-induced nephropathy.
- Vascular access complications are a great concern due to concomitant
peripheral arterial disease and increased arterial calcification.
- Lower use of DES may be justified due to the concern of patient
compliance with dual antiplatelet therapy. Concomitant issues such as family
support, memory problems and cost may prevent patient adherence to DAPT. Risk
of non-access site bleeding is also high in these patients, may interrupt dual
therapy and pose a risk of stent thrombosis.
Optimal care of CAD in octogenarians will involve risk factor reduction,
patient and family education on the natural history of the disease, and PCI in
the appropriate subset after a well-informed patient consent. Careful PCI with
safe vascular access, judicious use of anticoagulant therapy and use of BMS are
pivotal in the care of octogenarians who need PCI.
Aravinda Nanjudappa, MD
Cardiology Today Intervention Editorial Board Member
Disclosures: Dr. Nanjudappa reports no relevant financial disclosures.