|
 And while the rate of deaths after PCI is higher for these
nonagenarians than it is for younger patients, the benefits can
outweigh the risks for some, Dr. Abhishek Sawant of the State
University of New York at Buffalo and colleagues found. “We did show
that patients who had lower risk and underwent this procedure
actually did very well,” Sawant told Reuters Health in a telephone
interview.
PCI has been used for decades to restore blood flow in patients
having a heart attack, and in patients with severe chest pain that
doesn’t respond to other treatment. To better understand the risks
and benefits associated with PCI in older patients, Sawant and his
colleagues looked at medical data from the U.S. Department of
Veterans Affairs on more than 67,000 veterans who underwent PCI
between 2005 and 2014.
Overall, nonagenarians represented 0.4 percent of the group, but
that proportion increased from 0.25 percent in 2008 to 0.58 percent
in 2014.
Thirty days after the procedure, 10.6 percent of the nonagenarians
had died, compared to 1.4 percent of the younger patients. Mortality
one year after the procedure was 16.3 percent versus 4.2 percent,
according to the results in JACC: Cardiovascular Interventions.
After the researchers took factors such as patients’ other health
problems into account, they found that the nonagenarians were still
about twice as likely to die within 30 days of PCI, and their
one-year mortality was also roughly doubled compared to younger
patients.
Sawant’s team also found they could predict mortality among the
nonagenarians based on the patient’s National Cardiovascular Data
Registry (NCDR) CathPCI score, which is a risk-assessment tool
widely used on people undergoing PCI but had not previously been
shown effective among people 90 and older.
Rather than rejecting a candidate for PCI out of hand based on age,
Sawant said, physicians can use the NCDR CathPCI score to assess an
individual’s risks, and then discuss these risks and potential
benefits with the patient and his or her family. In these very old
patients, he noted, PCI may not substantially extend life, but by
easing chest pain, it can make important differences in their
quality of life.
One caution about the study findings, the researcher noted, is that
almost all the study participants were male - and the great majority
of nonagenarians are female.
[to top of second column] |
Another limitation of the study is that the "excellent" results of
PCI in this over-90 population were not compared to similar patients
who didn't get PCI, writes Dr. David Holmes of the Mayo Clinic in
Rochester, Minnesota, in an editorial accompanying the study. Still,
the study provides valuable information for doctors looking to
"optimize" longer-term treatment for these patients, he writes.
“What’s been shown in multiple studies over the years is that
chronological age alone should not be an exclusion to performing
percutaneous coronary intervention in appropriately selected
patients,” said Dr. Adam Skolnick of NYU Langone Medical Center in
New York who specializes in geriatric cardiology.
“The study confirms that in appropriately selected patients the
procedure can be performed safely with a low risk of complications,”
he told Reuters Health in a telephone interview.
About half of the nonagenarians in the study had PCI on an emergency
basis to treat a heart attack, he noted. “If someone is in the
throes of a myocardial infarction, time is of the essence,” Skolnick
said. “Usually unless there’s a really strong contraindication we
would proceed with PCI.”
But for non-emergency situations, for example to treat chest pain,
“I think these are individual decisions that should not be based on
simple risk scores. They have to include a discussion between the
patient and/or caregiver and the treating doctors,” Skolnick said.
The patient’s goals should be central to any decisions made about
whether to undergo PCI, he added, and if that goal is to live
longer, it’s not clear that non-emergency PCI will extend life in
this age group.
SOURCE: http://bit.ly/2vctn6e and http://bit.ly/2u8vNGa JACC:
Cardiovascular Interventions, online July 10, 2017.
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