Selection bias persists in complex, high-risk PCI
Data from a retrospective analysis show there are significant differences in the types of complex high-risk PCI cases undertaken across centers in England and Wales, as well as differences in clinical outcomes across age groups.
“The nature of complex, high-risk cases undertaken in elective PCI vary by age, with a lower prevalence of cardiometabolic risk factors among more elderly patients,” Mamas A. Mamas, DPhil, MRCP, professor of cardiology in the Keele Cardiovascular Research Group at Keele University in Staffordshire, U.K., told Healio. “This to my mind would suggest an element of selection bias, with only lower-risk elderly patients referred for PCI.”
In a retrospective study, Mamas and colleagues analyzed national registry data on complex, high-risk PCI in patients with stable angina in England and Wales from 2006 to 2017, stratified by three age groups: younger than 65 years; 65 to 79 years; and 80 years or older.
Of 424,290 elective PCI procedures, 33% were considered complex high-risk cases. Of those, 33.7% were performed in adults younger than 65 years; 42.9% were performed in adults aged 65 to 79 years and 23.4% were performed in adults aged at least 80 years.
Among complex high-risk types, chronic total occlusion (49.2%), prior CABG (30.4%) and severe vascular calcification (21.8%) were common among adults younger than 65 years. CABG (42.9%), CTO (32.9%) and severe vascular calcifications (27%) were common among adults aged 65 to 79 years; and prior CABG (15.8%), severe vascular calcification (15.5%) and chronic renal failure (11.1%) were common among octogenarians.
Compared with adults younger than 65 years, those aged 65 to 79 years were more likely to experience adverse outcomes, including death (adjusted OR = 1.7; 95% CI, 1.3-2.3), major bleeding (aOR = 1.3; 95% CI, 1.1-1.5) and MACCE (aOR = 1.2; 95% CI, 1-1.3). Octogenarians were more than twice as likely to experience mortality (aOR = 2.6; 95% CI, 1.9-3.6); and more likely to experience major bleeding (aOR = 1.4; 95% CI, 1.1-1.7) and MACCE (aOR = 1.3; 95% CI, 1.1-1.5) compared with younger adults.
“Given that our population is aging, coronary calcification will increasingly become a common complex, high-risk factor in future PCI practice, and algorithms will need to be further refined when undertaking such cases in the elderly populations, particularly now that several options exist for calcium modification strategies,” Mamas told Healio. “Complex, high-risk PCI was common among patients of all age groups with significant left ventricular dysfunction. Given the findings of the recent REVIVED-BCIS2 study, the role of elective PCI in this group of patients, particularly those without symptoms, will need to be reappraised.”
Mamas said consensus is needed on what is meant by “complex” PCI, as there is no uniformly accepted definition.
“We will require analysis of longer-term outcomes of these patients, with a particular focus around antiplatelet choice and duration in these groups of patients,” Mamas said.
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For more information:
Mamas A. Mamas, DPhil, MRCP, can be reached at mamasmamas1@yahoo.co.uk; Twitter: @mmamas1973.
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