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DES May Be Preferable to BMS in Oldest Patients
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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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Wang TY. J Am Coll Cardiol. 2012;59:105-112.
Perspective
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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.
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