Introduction

Coronary angioplasty is approaching its 45th anniversary, beginning in 1977 when Andreas Gruentzig performed the first human angioplasty intraoperatively during bypass surgery¹ and later that year performed coronary angioplasty as a primary revascularization procedure. The field has rapidly evolved with the introduction of bare metal stents in 1986 which significantly improved safety and success of percutaneous revascularization procedures.² This was later followed by the introduction of drug eluting stents in the early 2000's. Simultaneously, the field of interventional cardiology has expanded in the structural domain with the percutaneous closure of patent foramen ovale, atrial, and ventricular septal defects with the first successful human atrial septal defect (ASD) closure in 1975.³ Structural interventions further included percutaneous valve interventions, with the first transcatheter valve implant in 2002 that continued to evolve and improve until present day.

These therapies have specifically increased opportunities of percutaneous treatment for older adults sparing them the more invasive surgical approach. As a consequence of these advances, longevity has increased, and the older adult population has expanded at a rapid pace. In the past few decades, interventional cardiology practice is seeing an ever-larger population of older patients, particularly those above 75 years of age with complex coronary anatomy and structural heart disease pathology. Despite the opportunities for treatment, older patients should be screened for geriatric syndromes including frailty, cognitive impairment, physical dysfunction, and falls, as these conditions can affect therapeutic decisions and impact health outcomes after coronary and structural interventions.

The goal of this review is to provide a succinct approach to evaluation and management of older patients undergoing invasive cardiovascular procedures.

Geriatric Syndromes

Frailty

• Definitions
  • It is a state of increased vulnerability to stressors due to decreased physiological reserve described over a spectrum from robust (without frailty) to pre-frail and physically frail.⁴
  • Most widely accepted definition was proposed by Fried et al., "a clinical syndrome of increased vulnerability resulting from age associated decline in reserve and function across multiple physiologic systems such as the ability to cope with everyday acute stress is compromised."⁵
  • Fried et al. developed a tool to measure frailty which is based on two large epidemiological studies: The Cardiovascular Health Study and the Women's Health and Ageing Study. It measures frailty as greater than or equal to three abnormal domains of the following: shrinking or weight loss, weakness, poor endurance and energy, slowness, and low physical activity level.⁵
  • However, because it was developed for outpatient practice, it is less practical to use this tool in cardiovascular practice. A simpler and more practical tool using readily available data and simple objective measures was developed by Dr. Jonathan Afilalo and colleagues; the Essential Frailty Toolset was mainly utilized in cardiovascular practice. It uses biomarkers like serum albumin and hemoglobin combined with an assessment of cognitive function using the mini-mental state examination or Mini-Cog© scale and physical function utilizing the chair rise test.⁶
• Relevance
  • Pre-frailty and frailty are independently associated with a higher risk for developing cardiovascular disease (CVD), morbidity, and mortality. As compared to non-frail subjects, pre-frail and frail older patients had a higher incidence of major adverse cardiac events including mortality during a 6-year follow-up period.⁷
  • In the periprocedural period, hospital environment with immobilization, fasting, sleep deprivation and loss of muscle mass and function can rapidly worsen frailty and in turn CVD. CVD can in turn worsen frailty status.
• So what?
  • Identification of frailty in older adults undergoing cardiovascular interventions is essential. Interventions to prevent, reverse, or delay onset of frailty may lead to improved cardiovascular outcomes and overall health status after cardiovascular interventions.

Cognitive Impairment

• Association with CVD
  • Prevalence of cognitive impairment increases with age and CVD further worsens cognitive function.^8,9
  • Atrial fibrillation was associated with an 87% excess risk of development of dementia when subjects were followed over 15 years, after adjusting for confounders including alcohol consumption, smoking, diet, physical activity, diabetes, hypertension, heart failure, and CVD.⁸
  • In a cross-sectional study, patients with heart failure had a high prevalence of cognitive impairment.⁹
  • Proposed mechanisms include shared risk factors with CVD and dementia which may lead to neurodegeneration, CVD leading to clinical or subclinical strokes causing cognitive impairment, or CVD decreasing cerebral perfusion.¹⁰
• Relevance to patient outcomes
  • Cognitive impairment can lead to decreased medication adherence^11,12
  • Increased incidence of delirium in the hospital setting leads to increased hospital length of stay, further cognitive decline, rehospitalization, and death.¹³
• Screening and its utility
  • MiniCog© assessment may identify patients at risk for poor medication adherence or hospital delirium. Utilizing resources to optimize the patient's environment and minimize the risk of medication nonadherence may improve patient outcomes.

Falls

• Falls can cause impaired function, morbidity, mortality, and poor quality of life in older persons.
• Many cardiovascular medications including vasoactive medicines and atrioventricular nodal blocking drugs may contribute to falls. These geriatric patients with CVD are frequently prescribed multiple medications as a result of their comorbidities, which can further accentuate the negative effects of some cardiovascular medications, resulting in falls.¹⁴
• Falls present with a bleeding risk which results in challenges of weighing risks and benefits to anticoagulation or prolonged antiplatelet therapy in older adults undergoing complex coronary or structural heart disease interventions.
• Fall risk and polypharmacy must be assessed prior to prescribing most cardiovascular medications.

Interventional Cardiology Studies

Intervention Studied	Subjects	Results
PCI for STEMI and Cardiogenic Shock15	111,901 encounters for patients 75 years or older	Those who were not treated with PCI were more likely to be older, female and of an underrepresented minority. 50% decreased mortality odds with treatment by PCI in older adults. Older adults who were not treated with PCI had shorter mean hospital LOS, lower mean total hospital charges, and higher crude mortality rate.
All PCIs16	7,482 octogenarians and 102,236 younger patients	Octogenarians were more likely to have intervention performed for urgent reasons. Octogenarian mortality was more than threefold that of the younger cohort. Procedural success was less, and likelihood of complications were higher in the octogenarian cohort. Cardiogenic shock, acute MI without shock, LVEF<35%, renal insufficiency, first PCI, age>85 years and diabetes mellitus were all independent predictors of in-hospital death for octogenarians.
PCI for STEMI17	568 patients of which 99 were 75 years or older	Patients aged 75 years or older had an increased delay of treatment between time of chest pain onset and revascularization. Older patients were more likely to be treated with clopidogrel rather than more potent anti P2Y12 antiplatelet therapies. Older patients were less likely to be treated with drug-eluting stents.
Outcomes by sex in Acute MI and cardiogenic shock18	134,501 admissions 75 years or older including 69,220 women	Older women had lower use of coronary angiography, PCI, MCS, mechanical ventilation and HD as compared to older men. Female sex was associated with higher in-hospital mortality. Female sex was associated with more frequent discharges to a skilled nursing facility.
Guideline-Based Medications after PCI in Japan19	815 participants aged 63 and above divided into "pre-old" group (63-72 years) and "old" group (73 years and above)	Statins were less likely to be prescribed for the old group and for men.
PCI vs. CABG in unprotected left main CAD20	Meta-analysis of 16 studies with 4,880 patients in patients with mean age greater than 70 years	PCI was associated with lower rate of stroke at 30-day follow-up in octogenarians, but overall higher rate of repeat revascularization and nonfatal MI as compared to CABG. PCI was associated with increasing mortality with advancing age as compared to CABG, however there is a high likelihood of referral bias where older patients underwent PCI instead of CABG.
PCI vs. CABG in left main or multivessel CAD21	1,079 adults aged 70 to 89 years	Older adults undergoing CABG had lower rates of death from any cause, MI, stroke or repeat revascularization compared to the PCI group. The advantage of CABG was greater in patients with high SYNTAX scores.
Acute MI undergoing surgical, interventional, or medical management22	3,041 patients age 75 years or older	The incidence of ADL decline was the lowest among patients who underwent CABG compared with PCI or medical management. CABG and PCI were both associated with a lower risk of functional decline and decreased health-related quality of life compared to those who underwent medical therapy.
Syncope patients with at least 1-vessel obstructive CAD undergoing PCI	9,549 patients age 65 years and older of whom 3,196 underwent PCI	PCI treated patients had significantly higher risk of readmission for MI, but a lower risk of long-term mortality as compared to medically managed patients.
CABG vs. PCI and Memory Decline23	1,680 patients age 65 o older	There was a significant increase in rate of memory decline after off-pump CABG compared with PCI, however not after on-pump CABG. The type of revascularization procedure is not significantly associated with differences in memory decline.
PCI in Acute Coronary Syndrome24	6,720,281 patients aged 70 or above	Rate of PCI in older adults increased from 1998 to 2013. PCI was associated with lower in-hospital mortality and length of hospital stay in the elderly with acute MI.
Revascularization Strategy in Acute MI and Multivessel Disease25	50,632 patients 65 years or older	In STEMI patients, multivessel intervention during index PCI was associated with a higher 30-day and 1-year mortality compared to culprit-only intervention. There was no significant mortality difference in NSTEMI patients.
Frailty in TAVR or SAVR (FRAILTY-AVR Study)6	1,020 patients median age 82 years	Frailty as measured by the Essential Frailty Toolset was the strongest predictor of death at 1 year, worsening disability at 1 year and death at 30 days.
Bleeding Risk in AVR26	1,195 patients with mean age 81 years	Frailty measured using the Essential Frailty Toolset was an independent predictor of major bleeding and need for transfusions. Major bleeding was associated with a 3-fold increase in 1-year mortality following SAVR and TAVR.
Habitual Physical Activity in TAVR27	755 patients with median age of 84 years	Sedentary patients were more likely to be older, female, frail, cognitively impaired, depressed and have multimorbidity. Lower habitual physical activity was associated with increased 1-year mortality, longer length of stay, discharge to healthcare facilities, and disability. Pre-existing frailty was interpedently predictive of worsening habitual physical activity following TAVR.
Sarcopenia in TAVR28	300 patients with mean age 79 years	Sarcopenia was more common in men as compared to women. Pre-TAVR muscle strength positively correlated with skeletal muscle index. Higher skeletal muscle index was associated with shorter hospital length of stay and increased 1-year health-related quality of life.
Access Site for TAVR29	728 patients with mean age 84 years	In frail patients, nonfemoral access was associated with increased 30-day and 1-year mortality whereas in non-frail patients, nonfemoral access had no effect.
Delirium after AVR30	187 patients undergoing SAVR or TAVR	The risk of delirium increased for lower short physical performance battery scores. A model based on the following components: gait speed, chair stands, MMSE, isolated SAVR or SAVR and CABG predicted delirium well with a C statistic of 0.71.

Approach to Geriatric Syndromes

• Screening to identify geriatric syndromes among older adults undergoing cardiovascular interventions is critical.
• Individualized care plans must be considered to address the patient's primary cardiac conditions in the context of the geriatric syndromes, i.e., falls, cognitive impairment, frailty.¹⁴
• Physical, exercise-based interventions like tailored cardiac rehabilitation to prevent or improve frailty has the potential to improve post-procedural outcomes and decrease cardiovascular morbidity and mortality, although more research is needed to confirm its impact.
• Whereas guidelines issued by the National Institutes of Health (NIH) Office of Research on Minority Health in 1994 require the NIH to ensure that women and minorities are included in all NIH-supported human subjects research, recent initiatives have focused on inclusion of older adult populations in research studies. Age cutoffs in clinical trials limit the generalizability of results to a rapidly growing older adult population which represents the majority of patients in cardiovascular practice. A more pragmatic trial that encompasses older patients are needed with a systematic approach to measure geriatric syndromes and their influence of post-procedural outcomes.

Summary

Data suggests that older adults are less frequently treated with invasive cardiovascular interventions, like PCI, and guideline directed medical therapy are not fully utilized, as compared to younger adults. Whereas older adults are affected by geriatric syndromes that need to be considered when making therapeutic decisions, data also suggests that interventions, i.e., CABG and PCI in older adults, when indicated, improve mortality and cardiovascular outcomes.

Older patients undergoing cardiovascular interventions should be screened for geriatric syndromes including frailty, cognitive impairment, physical dysfunction, and falls so that individualized therapeutic decisions can be made to address the interaction between cardiovascular therapies and geriatric risks. Data is emerging on optimal interventions that can prevent or reverse geriatric syndromes among older adult populations.

References

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Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and Structural Heart Disease, Exercise, Hypertension, Sleep Apnea

Keywords: Aged, Frail Elderly, Cross-Sectional Studies, Quality of Life, Drug-Eluting Stents, Platelet Aggregation Inhibitors, Cardiovascular Diseases, Prevalence, Follow-Up Studies, Accidental Falls, Atrial Fibrillation, Foramen Ovale, Patent, Length of Stay, Longevity, Outpatients, Sleep Deprivation, Risk Factors, Risk Assessment, Heart Failure, Cognition, Weight Loss, Heart Septal Defects, Ventricular, Medication Adherence, Cerebrovascular Circulation, Exercise, Anticoagulants, Outcome Assessment, Health Care, Serum Albumin, Hypertension, Angioplasty, Hemoglobins, Biomarkers, Dementia, Delirium, Diabetes Mellitus, Hospitals, Mental Status and Dementia Tests, Pharmaceutical Preparations, Stroke, Cardiac Rehabilitation, Percutaneous Coronary Intervention, National Institutes of Health (U.S.), Coronary Artery Bypass

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