Expert: Revascularization may help elderly patients with CAD

WASHINGTON — Elderly patients with CAD may be at higher risk for adverse outcomes and complications, but revascularization is beneficial in this patient population and should still be considered as a treatment strategy, a speaker said at the American College of Cardiology Scientific Session.

Although diagnostic tests and revascularization are underutilized in elderly patients with CAD, information from the National Cardiovascular Data Registry (NCDR) indicates that 39% of all PCIs are performed in patients aged 65 to 80 years, with about 28% of all PCIs performed in those older than 80 years. However, procedural use is still reduced as a function of age, according to Cindy L. Grines, MD, FACC, FSCAI, chief of cardiology at Hofstra Northwell Medical School and academic chief of cardiology at Northwell Health System, Manhasset, New York.

“There are a lot more elderly patients presenting with coronary disease,” she said during a presentation. “Even though the 28% of procedures overall are being performed in patients with advanced age, the proportion of procedures performed in those aged 80 to 90 years is really quite low compared with the younger population presenting to the hospital with ACS.”

Physicians may be hesitant to perform revascularization in elderly patients for several reasons, including increased mortality and increased risk for complications, such as stroke, renal failure, congestive HF, bleeding complications and more, Grines noted.

“In this era of scorecard medicine, we don’t want to take a hit for treating an elderly patient who might have a complication,” she said, highlighting NCDR data showing that patients aged 65 to 70 years have better overall survival after PCI than those aged older than 75 years. “We do know that survival — acutely as well as long-term — is reduced in patients relative to their age.”

Benefits of revascularization in elderly

Despite the increased risk for death and complications in elderly patients, revascularization may still improve outcomes, Grines said.

PAGE BREAK

“The interesting thing is that we don’t really avoid primary PCI because we know that it’s much better than thrombolytic therapy,” she said. “We do know that in the acute MI setting, primary angioplasty is quite beneficial in the older population.”

The same appears to be true for elderly patients with unstable angina or non-STEMI, with study results showing the greatest benefit of an invasive approach in patients older than 65 years, compared with younger patients.

Patients who are even older may benefit, according to Grines. She cited data from the After Eighty ACS study, which showed that reinfarction and the need for urgent revascularization were dramatically reduced with an invasive treatment strategy vs. a conservative treatment strategy in patients older than 80 years with ACS. Although the study was underpowered to examine mortality or stroke, Grines said the data suggest that elderly patients who present with unstable angina or non-STEMI should be offered angioplasty as opposed to conservative care.

Evidence also indicates that an invasive approach may be beneficial in older patients with stable angina, according to Grines. She highlighted data from the TIME trial demonstrating a reduction in MACE with invasive treatment vs. optimal medical therapy in patients with chronic stable angina older than 75 years. However, similar to the After Eighty ACS study, the benefit was seen with softer endpoints, such as urgent revascularization.

“We can’t say we’re doing much other than improving these patients’ quality of life — improving their angina status — but we’re probably not going to be able to reduce the risk for death or MI,” Grines said. “The bottom line, though, is that even in elderly patients with stable angina, they are going to get some benefit from PCI.”

PCI vs. CABG

Although data support revascularization in the elderly, evidence is conflicting about whether PCI or CABG may be best in this patient population, Grines said.

Complication rates for both treatment approaches are increased in the elderly, but risk for death, stroke, transient ischemic attack, coma and renal failure are significantly higher after CABG for patients older than 80 years vs. younger patients.

Even so, data comparing PCI with CABG in older patients showed that mortality at 3 years was not significantly different after PCI vs. CABG at 3 years, but in the early stages, mortality was superior with PCI vs. CABG.

“This brings up an important point because we focus a lot on that long-term mortality, but when you’re 85 or 90 years old, what you want is to survive the next month or the next 6 months,” Grines said. “For the older patients, it’s very important to avoid complications, and short-term mortality for them is every bit as important as long-term mortality.”

Physicians might also consider off-pump CABG to avoid stroke, Grines noted. However, one randomized study in patients aged older than 75 years comparing off-pump with on-pump CABG demonstrated no significant difference between the two approaches in the risk for death, stroke or MI. In fact, more repeat revascularization was noted among patients who underwent off-pump CABG.

PAGE BREAK

“Even with older patients, I’m not convinced this is the answer to avoiding strokes,” she said.

Importance of patient selection

In a number of large, national, observational registries, advanced age is the No. 1 reason that patients are deemed ineligible for surgery, according to Grines.

Because older patients benefit from revascularization, however, the question is whether age should be such a major factor. She noted that other problems, such as lung disease, severe left ventricular dysfunction and renal insufficiency, would play a bigger role in her decision. However, one study showed that surgical “ineligibility” conferred a fivefold higher risk for mortality that could not be accounted for by Society of Thoracic Surgeons score, EuroSCORE or NCDR risk score.

Additionally, she said two elderly patients may be the same on paper and have the same comorbidities, but they may differ in other important ways. For instance, in one study, mortality after PCI was 28% for frail patients vs. 6% for nonfrail patients, and risk for death or MI was 41% for frail patients vs. 17% for nonfrail patients. Furthermore, frailty and quality-of-life score were independent predictors of mortality.

“Surgeons are able to look at the patients and come up with a good assessment of risk. They look at variables that interventional cardiologists typically don’t consider, but perhaps we should be weighing those factors before taking a high-risk elderly patient to the cath lab,” Grines said.

Overall, although complication rates are higher, revascularization does appear to improve outcomes in elderly patients, she noted.

“Therefore, we have to use some sort of scoring tool to select patients who are most likely to benefit,” Grines said. “We really need to use strategies to avoid stroke and renal failure, and strong consideration should be given to using radial access to reduce bleeding complications.” – by Melissa Foster

Reference:

Grines CL. Core curriculum: Revascularization in special populations. Presented at: American College of Cardiology Scientific Session; March 17-19, 2017; Washington, D.C.

Disclosure: Grines reports receiving consultant fees or honoraria from Abbott Vascular, Boston Scientific and the Volcano Group, and receiving salary from the Journal of Interventional Cardiology.