Percutaneous Coronary Interventions

Percutaneous coronary interventions (PCIs)--eg, percutaneous transluminal coronary angioplasty (PTCA), coronary stenting, rotational atherectomy, directional atherectomy--are less invasive than CABG and require a shorter recovery time. These benefits are particularly advantageous in elderly patients, especially those with coexisting noncardiac disorders that may adversely affect short-term and long-term outcomes.

In the USA, > 50% of PCIs are performed in patients > 65. Elderly patients undergoing PCI are sicker than younger patients undergoing this procedure: They have more extensive coronary artery disease and are more symptomatic, and they more frequently have class III angina (angina with light exercise), class IV angina (angina with minimal activity), or unstable angina.

Prognosis

The technical feasibility of PCI in the elderly is well established. The initial success rate ranges from 92 to 99%, which approximates the success rate for younger patients. The success rate is high even for very old patients.

For patients with multivessel coronary disease, the 5-year survival rate with PTCA is similar to that with CABG, although diabetic patients have a better survival rate when treated with CABG. However, most patients undergoing PCI now receive stents, which lower the rate of abrupt vessel closure and restenosis. In addition, antiplatelet glycoprotein IIb/IIIa receptor antagonists (eg, abciximab, tirofiban, eptifibatide) can reduce acute complications of PCI, including mortality, and are now widely used.

Mortality and morbidity rates with PCI are highest for the oldest patients, largely because these patients are frail and have advanced disease. Also, in these patients, complications are more likely to cause death. The hospital mortality rate is < 0.5% for patients < 65 but 2.2 to 4% for patients > 75. The most powerful predictor of mortality (see Table 96-1) is diffuse coronary artery disease. Poor left ventricular function and age per se are also independent predictors of periprocedural mortality. The complication rate for elderly patients (9%) is only slightly higher than that for younger patients (6%). Postprocedural renal failure and bleeding complications are more common in elderly patients undergoing PCI than in younger patients.

The overall long-term survival rate after PCI is good, even for patients > 75. The rate (about 85% at 4 years) is comparable with that for younger patients.

Excellent long-term relief of symptoms is achieved in most elderly patients with angina. However, angina patients > 75 who undergo PTCA appear to have higher recurrence rates of symptoms than do younger patients, probably even with stenting. A possible reason for their higher recurrence rates is that these patients are less likely to achieve complete revascularization than are younger patients. Overall, restenosis occurs in 15 to 30% of successful PCI cases and does not appear to be more common in the elderly. Risk of recurrent angina appears to depend largely on the extent of coronary artery disease before PTCA.

Preprocedural Assessment

The decision to perform revascularization and to choose CABG or PCI should not be based principally on age. However, physiologic age and general physical condition are important considerations. The physician must consider the significance of coexisting noncardiac disorders, the patient's ability to tolerate drugs, the patient's activity level and expectations, and the technical feasibility of the revascularization procedure. Enhancing independence and quality of life are important goals of treatment.

Postprocedural Treatment

The postprocedural treatment for elderly patients is similar to that for younger patients. Elderly women in particular have a higher rate of femoral hematomas; important aspects of management include weight adjustment of the heparin dosage, early discontinuation of femoral lines, and meticulous puncture site care.