From SCAI 2012 & EuroPCR: Are the 90s the New 80s?
The Society for Cardiovascular Angiography and Interventions (SCAI, pronounced “sky”) met in May for their annual meeting, while EuroPCR met just a few days later in Paris. The following are some of the highlights from the two meetings.
Las Vegas and Paris—Recent census data indicate the number of people 90 years of age or older in the United States has tripled since 1980 to nearly 2 million. Despite this growing population, let’s face it: there are not a lot of outcomes data for this population undergoing PCI for STEMI.
Of 3,367 consecutive STEMI patients treated with PCI at the Minneapolis Heart Institute over about an 8.5-year period, 65 (1.9%) were >90 years old and three-fourths were women. Results, presented at SCAI in Las Vegas, were fairly comparable to those seen in the 419 patients in their 80s undergoing PCI. Length of stay was identical and there was actually less major bleeding seen in the group in their 90s. In-hospital death was a little higher, but not much: 12.1% versus 10.7%.
So, the authors concluded, nonagenarians with STEMI have reasonable outcomes with PCI and should be considered for reperfusion therapy.
At EuroPCR in Paris, investigators from the University of Torino, Italy, conducted a systematic review to evaluate PCI outcomes in nonagenarians. They evaluated nine studies reporting on a total of 429 patients in their 90s undergoing PCI with stenting, with nearly all admissions for ACS. In-hospital death was 13.13% with major adverse coronary events in 15.17%. After a follow-up of 1 to 60 months (median = 12 months), risk of long-term death was 32.04% (slightly higher with MACE [37.48%]).
In what the authors believe is the largest cohort of nonagenarians undergoing PCI and stenting, the feasibility is established even for this very frail patient subset. With an acceptable risk profile, recent clinical instability, and/or disabling symptoms, patients in their 90s should not be denied the possibility of PCI in experienced hands.
TAVR for The 90s
Again, not a surprise, but there are few data on nonagenarian patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). At SCAI, Keita Yamasaki, MD, PhD, Karolinska University Hospital, Stockholm, Sweden, reported on 22 consecutive patients between 90 and 96.8 years of age with severe aortic stenosis who were not candidates for surgery and underwent TAVR. Follow-up ranged from 30 days to more than 3.5 years (570±378 days) with no deaths in the first 30 days (0/22) nor in the first year (0/15). Two deaths occurred subsequently: one after 398 days and the other 868 days post-procedure.
One patient experienced a stroke during the procedure and five required permanent pacing due to AV block following the procedure. All patients were discharged to their homes.
This is a patient population that previously was largely untreated and, as a consequence, had high rates of morbidity and mortality when denied surgery. Now, it seems that TAVR may be a safe and effective treatment for severe aortic stenosis in select nonagenarian patients.
For the younger octogenarian population, data presented at EuroPCR looked at outcomes with the Nobori (Terumo Corporation, Tokyo, Japan) drug-eluting stent with a biodegradable polymer. The NOBORI 2 investigators analyzed 3,067 patients, 190 of whom were older than 80 years of age. In this older group, more than 90% of patients received at least 6 months of dual antiplatelet therapy (DAPT), with 69.6% remaining on DAPT at 1 year, which was similar to the 73.4% of younger patients on DAPT at the same 12-month mark.
Despite the advanced age, multiple comorbidities, and high percentage of patients treated for ACS, the outcomes for the elderly patients at 3 years was good and 88% were free of angina in both the older and younger groups (80 years of age and younger). No very-late stent thrombosis was observed in the octogenarians, suggesting that it’s a suitable treatment option for this vulnerable population.
Similar good news emerged from an analysis of 302 patients (mean age 88±2 years) who underwent PCI at Royal Bournemouth Hospital, United Kingdom. A total of 183 patients were treated for ACS while 119 were elective cases.
Thirty-day and 1-year mortality rates were 4.6% and 17.2%, respectively, for the entire cohort, with no significant difference between the patients with ACS and elective PCI patients. Excluding shock patients, 1-year mortality was 16.4% in the ACS group versus 13.8% for the elective PCI group (p = 0.55.) Per-year incremental increases in age, male sex, previous PCI, and shock were independent predictors of 1-year mortality.
Finally, Ulrike Krumsdorf, MD, et al. of the University of Heidelberg, Germany, prospectively studied 87 patients who were at least 81 years of age or older when they underwent TAVR. Eight survived for 6 months and were assessed. Analysis showed a highly significant clinical benefit of transfemoral TAVR, affecting both physical and mental quality of life which persistently improved post-TAVR. All eight health components measured improved significantly after TAVR, with the highest gain seen in physical functioning scores (p < 0.0001).
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