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PCI in elderly patients PCI in elderly patients Presentation Transcript

  • PCI IN ELDERLY - DEV PAHLAJANI MD,FACC,FSCAI CHIEF OF CARDIOLOGY, BREACH CANDY HOSPITAL,MUMBAI
  • ELDERLY POPULATION: A GROWING GLOBAL CHALLENGE• IN USA, 35 MILL…………….IN 2000• 82 MILL…………………………. IN 2030 ABOVE 80 YRS. 9.3 MILLION TO DOUBLE BY 2030
  • GRACE: FOR HIGH RISK ACS AGE 18466 patients dynamic ECG changes +ve cardiac markers 44% > 70 yrs. < 70 yrs.-10380 70-80 - 5057 80 + - 3029
  • DEFINITION OF ELDERLY NO UNIVERSALLY ACCEPTED DEFINITION  WHO: 60 YRS. MOST US CLASSIFICATION 65 AND ABOVE  GRACE ACS 70YRS.
  • Management and 6-month Outcomes in Elderly and Very Elderly Patients withHigh-Risk non-ST-elevation Acute Coronary Syndromes: The Global Registry of Acute Coronary Events Gerard Devlin, Joel M. Gore, John Elliott, Namal Wijesinghe, Kim A. Eagle, Álvaro Avezum, Wei Huang and David Brieger for the GRACE Investigators
  • Inhospital events for high-risk patients with NSTE-ACS <70 years (n = 10 380) With PCI/CABG Without PCI/CABG 45% (n = 4612) 55% (n = 5694)CHF/pulmonary oedema, n (%) 316 (6.9) 488 (8.6), P < 0.01Recurrent ischaemia, n (%) 1169 (26) 1311 (23), P < 0.01Major bleeding, n (%) 102 (2.2) 73 (1.3), P < 0.001Stroke, n (%) 21 (0.4) 20 (0.4), P = 0.6Death, n (%) 87 (1.6) 203 (2.9), P < 0.001 Eur. HJ 2008, 29, 1275
  • Inhospital events for high-risk patients with NSTE-ACS 70–80 years (n = 5057) With PCI/CABG Without PCI/CABG 35% (n = 1741) 65% (n = 3291)CHF/pulmonary oedema, n (%) 243 (14) 623 (19), P < 0.0001Recurrent ischaemia, n (%) 533 (31) 775 (24), P < 0.0001Major bleeding, n (%) 57 (3.3) 89 (2.7), P = 0.25Stroke, n (%) 22 (0.7) 16 (0.9), P = 0.3Death, n (%) 95 (4.3) 262 (6.2), P < 0.001 Eur. HJ 2008, 29, 1275
  • Inhospital events for high-risk patients with NSTE-ACS >80 years (n = 3029) With PCI/CABG Without PCI/CABG 21% (n = 620) 79% (n = 2390)CHF/pulmonary oedema, n (%) 124 (20) 539 (23), P = 0.2Recurrent ischaemia, n (%) 182 (29) 511 (22), P < 0.0001Major bleeding, n (%) 43 (7.0) 80 (3.4), P < 0.0001Stroke, n (%) 3 (0.9) 21 (0.5), P = 0.45Death, n (%) 57 (7.0) 363 (11), P < 0.001 Eur. HJ 2008, 29, 1275
  • Reperfusion Therapy In Elderly Patients With Acute Myocardial Infarction : A Randomized Comparison Of Primary Angioplasty And Thrombolytic Therapy Menko-Jan de Boer, MD*, Jan-Paul Ottervanger, MD*, Arnoud W.J van’t Hof, MD*, Jan C.A Hoorntje, MD*, Harry Suryapranata, MD*, Felix Zijlstra, MD*, the Zwolle Myocardial Infarction Study Group Zwolle, the Netherlands
  • Clinical Course of the Two Patient Groups Angioplasty Streptokinase (n 46) p Value (n 41)Mortality in-hospital,n (%) 3 (7) 0.07 8 (20)Stroke, n (%) 1 (2) 0.34 3 (7)Recurrent AMI, n (%) 1 (2) 0.01 6 (15)Bleeding (noncerebral) 5 (11) 0.72 3 (7) JACC 2002, 39, 1723
  • 100 90 Overall Survival (%) PCI 80 P = 0.04 70 STK 0 1 2 yearOverall survival for patients randomized for angioplasty treatment (solid line)and thrombolysis Treatment (dotted line) during 24 6 months of follow-up(p = 0.04, relative risk: 2.5, 95% confidence interval: 1.0 to 6.2). JACC 2002, 39, 1723
  • 100 90 Survival free of reinfarction PCI or stroke (%) 80 70 P = 0.003 60 STK 50 0 1 2 yearOverall survival free of recurrent infarction or stroke for patients randomized forangioplasty treatment (dashed line) and thrombolysis treatment (doted line)during 24 6 months of follow-up (p = 0.003, relative risk: 3.1, 95% confidenceinterval: 1.4 to 7.0). JACC 2002, 39, 1723
  • Six-month outcomes for high-risk patients with NSTE-ACS <70 years (n = 10 380) With PCI/CABG Without PCI/CABG 45% (n = 4612) 55% (n = 5694)Death, n (%) 74 (1.7) 191 (3.5), P < 0.0001Myocardial infarction, n (%) 85 (2.2) 128 (2.9), P = 0.06Stroke, n (%) 18 (0.4) 46 (0.9), P < 0.01Triple endpoint, n (%) 170 (3.8) 337 (6.2), P < 0.0001Re-admission for cardiac 695 (17) 842 (16), P = 0.7event, n (%) Eur. HJ 2008, 29, 1275
  • Six-month outcomes for high-risk patients with NSTE-ACS 70–80 years (n = 5057) With PCI/CABG Without PCI/CABG 35% (n = 1741) 65% (n = 3291)Death, n (%) 50 (3.0) 268 (8.5), P < 0.0001Myocardial infarction, n (%) 51 (3.5) 141 (5.4), P < 0.01Stroke, n (%) 27 (1.7) 39 (1.3), P = 0.30Triple endpoint, n (%) 118 (7.0) 415 (13), P < 0.0001Re-admission for cardiac 275 (17) 647 (22), P < 0.01event, n (%) Eur. HJ 2008, 29, 1275
  • Six-month outcomes for high-risk patients with NSTE-ACS >80 years (n = 3029) With PCI/CABG Without PCI/CABG 21% (n = 620) 79% (n = 2390)Death, n (%) 69 (12) 420 (19), P < 0.0001Myocardial infarction, n (%) 27 (5.2) 146 (8.1), P = 0.03Stroke, n (%) 12 (2.2) 62 (3.1), P = 0.24Triple endpoint, n (%) 98 (17) 564 (25), P < 0.0001Re-admission for cardiac 128 (23) 531 (26), P = 0.1event, n (%) Eur. HJ 2008, 29, 1275
  • Six-month post-discharge outcomes in young, accordingto those who did and did not undergo revascularization. 40 30 P<0.0001 Patients (%) 20 P<0.01 17 15 P<0.0001 10 3.8 6.2 1.7 3.5 2.2 2.9 0.4 0.9 0 Death MI Stroke Triple endpoint Re-admission for cardiac Revasc + Revasc - illness Eur. HJ 2008, 29, 1275
  • Six-month post-discharge outcomes in elderly age groups according to those who did and did not undergo revascularization. 40 P<0.0001 30Patients (%) 22 20 P<0.0001 P<0.01 17 13 10 8.5 7 3 3.5 5.4 1.7 1.3 0 Death MI Stroke Triple Re-admission endpoint for cardiac illness Revasc + Revasc - Eur. HJ 2008, 29, 1275
  • Six-month post-discharge outcomes in very elderly age groups according to those who did and did not undergo revascularization. P<0.0001 40 P=0.03 P<0.0001 30 25 26Patients (%) 23 19 17 20 12 10 8.1 5.2 2.2 3.1 0 Death MI Stroke Triple endpoint Re-admission for cardiac illness Revasc + Revasc - Eur. HJ 2008, 29, 1275
  • Optimal Medical Therapy With or Without Percutaneous Coronary Intervention in Older Patients With Stable Coronary Disease A Pre-Specified Subset Analysis of the COURAGE(Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation) Trial • Koon K. Teo, MB, BCh, PhD*, Steven P. Sedlis, MD, William E. Boden, MD,*, Robert A. ORourke, MD, David J. Maron, MD||, Pamela M.Hartigan, PhD¶, Marcin• Dada, MD#, Vipul Gupta, MBBS, MPH, John A. Spertus, MD, MPH**, William J.Kostuk, MD, Daniel S. Berman, MD, Leslee J. Shaw, PhD, Bernard R.Chaitman, MD||||, G.B. John Mancini, MD¶¶, William S. Weintraub, MD## COURAGE Trial Investigators JACC 2009, 54, 1303
  • COURAGE TRIAL Primary and Secondary Outcomes by Treatment Arm and Age Group Age <65 Yrs (n = 1,381) OMT PCI HR p ValueOutcome (n = 693) (n = 688) (95% CI)Death 41 (6%) 25 (4%) 0.68 (0.42–1.10) 0.11MI 76 (11%) 83 (12%) 1.12 (0.82–1.53) 0.44Death/MI 110 (16%) 109 (16%) 1.01 (0.78–1.31) 0.93Death/MI/stroke 115 (17%) 115 (17%) 1.02 (0.79–1.33) 0.86ACS 85 (12%) 87 (13%) 1.03 (0.77–1.39) 0.83 JACC 2009, 54, 1303
  • COURAGE TRIAL Primary and Secondary Outcomes by Treatment Arm and Age Group Age >65 Yrs (n = 904) OMT PCI HR Interaction Outcome (n = 444) (n = 460) (95% CI) p Value p ValueDeath 54 (12%) 57 (12%) 1.01 (0.69–1.46) 0.97 0.21MI 52 (12%) 60 (13%) 1.14 (0.79–1.66) 0.48 0.95Death/MI 93 (21%) 104 (23%) 1.10 (0.83–1.45) 0.51 0.66Death/MI/stroke 99 (22%) 109 (24%) 1.08 (0.82–1.42) 0.58 0.77ACS 40 (9%) 49 (11%) 1.19 (0.79–1.81) 0.41 0.58 JACC 2009, 54, 1303
  • Survival of Elderly Patients Undergoing Percutaneous Coronary Intervention for Acute Myocardial Infarction Complicated by Cardiogenic Shock Han S. Lim, MBBS*,**, Omar Farouque, MBBS, FRACP, PhD, FACC*,, Nick Andrianopoulos, MBBS, MBiostat, Bryan P. Yan, MBBS, FRACP,, Chris C.S. Lim,MBBS||, Angela L. Brennan, RN, CCRN, Chris M. Reid, BA, MSc, DipEd, PhD, Melanie Freeman, MBBS*, Kerrie Charter, RN, CCRN*, Alexander Black, MBBS, FRACP,,¶, Gishel New, MBBS, FRACP, PhD, FACC||, Andrew E. Ajani, MBBS, FRACP, FJFICM,MD,,, Stephen J. Duffy, MBBS, MRCP, FRACP, PhD#, David J. Clark, MBBS, FRACP*,* on behalf of the Melbourne Interventional Group JACC Intv. 2009, 2, 146
  • Clinical Outcomes : In-Hospital Age ≥ 75 Years Age <75 Years p ValueIn-hospital (n = 143)Mortality 19 (42.2) 33 (33.7 0.33 Complications Periprocedural MI 2 (4.7) 2 (2.1) 0.41 Emergency PCI 1 (2.3) 1 (1.0) 0.53 Unplanned CABG 1 (2.3) 4 (4.3) 1.00 Bleeding 4 (8.9) 3 (3.1) 0.21 Congestive heart failure 18 (40.0) 25 (25.5) 0.08 Renal failure 13 (28.9) 12 (12.2) 0.02 Stroke 1 (2.2) 2 (2.0) 1.00 JACC Intv. 2009, 2, 146
  • Clinical Outcomes : 30 Days Age ≥ 75 Years Age <75 Years p Value30 days (n = 141)Mortality 19 (43.2) 35 (36.1) 0.42MI 2 (4.5) 3 (3.1) 0.65TVR 2 (4.5) 6 (6.2) 0.70MACE 22 (50.0) 40 (41.2) 0.33 JACC Intv. 2009, 2, 146
  • Clinical Outcomes : One year Age ≥ 75 Years Age <75 Years p Value1 year (n = 117) Mortality 20 (52.6) 37 (46.8) 0.56 Cardiac 17 (85.0) 34 (91.9) 0.65 Noncardiac 3 (15.0) 3 (8.1) 0.65 MI 2 (5.3) 3 (3.8) 0.66 TLR 3 (7.9) 5 (6.3) 0.71 TVR 3 (7.9) 6 (7.6) 0.96 MACE 24 (63.2) 42 (53.2) 0.31 JACC Intv. 2009, 2, 146
  • PCI IN AMI SHOCKKaplan-Meier Estimates of Cumulative 1-Year Survival JACC Intv. 2009, 2, 146
  • PCI IN AMI SHOCKKaplan-Meier Estimates of Cumulative 1-Year Freedom From MACE JACC Intv. 2009, 2, 146
  • PCI IN AMI SHOCK Multivariate Analysis of In-Hospital Mortality Variable Odds Ratio 95% CI p ValueRenal failure 3.41 1.21–9.63 0.02IABP use 2.11 0.97–4.59 0.06STEMI 0.55 0.22–1.38 0.20Diabetes 1.63 0.70–3.76 0.26Hypertension 1.59 0.69–3.63 0.27Age ≥ 75 years 1.04 0.46–2.36 0.93 JACC Intv. 2009, 2, 146
  • Long-Term Paclitaxel-Eluting Stent Outcomes in Elderly Patients Daniel E. Forman, MD; David A. Cox, MD; Stephen G. Ellis, MD;John M. Lasala, MD; John A. Ormiston, MD; Gregg W. Stone, MD; Mark A. Turco, MD; Jeanne Y. Wei, MD; Anita A. Joshi, MD; Keith D. Dawkins, MD and Donald S. Baim, MD Circ Card. Vasc. Intv. 2009 2, 178
  • 5-year cumulative rates of death (upper left), MI(upper right), Academic Research Consortium, definite/probable ST (lower left), and TLR (lower right) for patients receiving PES in the randomized trials Circ. Card. Vasc. Intv. 2009 2, 178
  • 5-year cumulative rates of death (upper left), MI (upper right), Academic ResearchConsortium, definite/probable ST (lower left), and target lesion revascularization (TLR) (lower right) for PES versus BMS in patients aged >70 years in the randomized trials Circ. Card. Vasc. Intv. 2009 2, 178
  • TAKE HOME MESSAGE PCI results in elderly are comparable with younger population due to improved tech. Hardware and des The results of PCI including multi site arterial involvement have become acceptable Number of elderly is growing due to improved longevity
  • Thank you!!