Percutaneous coronary intervention (PCI) is safe in some nonagenarians with ST-segment elevation myocardial infarction (STEMI) — a population commonly excluded from trials — a small study suggests.
A transradial strategy was chosen for 60% of the procedures. Revascularization of the culprit vessel was successful, reaching TIMI flow 2 or 3, in 86% of overall cases. After PCI, median left ventricular ejection fraction reached 41.5%, according to the investigation by Gérard Helft, MD, PhD, of Pitié-Salpêtrière Hospital in Paris, and colleagues reported in Heart.
In-hospital complication rates were fairly low, with mortality being the most common at 24%, followed by ventricular arrhythmia (17%), acute renal failure (10%), major bleeding (4%), and target vessel revascularization (4%). Only 1% of patients had a stroke.
Survival rates at 6 months and 1 year were 61% and 53%, respectively.
With the “unexpectedly low rate of complications,” the investigators suggested that “primary PCI can be safely and successfully performed in nonagenarians presenting with STEMI through a transradial approach.”
The benefits of primary PCI in the oldest-old should be reflected in public health measures, Helft’s group urged. The median of 5.8 hours it took to get to PCI from symptom onset was interpreted as widespread hesitation to treat this population.
“The earlier the diagnosis is made and the patient referred to the catheterisation laboratory, the better will be the outcome from primary PCI. … Additional data provided by our study may help to change current perceptions and potentially influence guidelines on the management of STEMI.”
Though the safety of PCI for selected nonagenarians has been reported previously, the study “again highlights that we should not exclude STEMI patients from PCI based on age alone,” according to Matias Yudi, MBBS, of Royal Melbourne Hospital in Australia.
Yudi, who was not involved in the investigation, claims to be “aggressive” in the management of selected elderly patients who previously had good cognitive and functional status. “Thus this study reinforces my current practice,” he told MedPage Today.
Helft’s retrospective multi-center study included 145 patients age 90 or older. All received primary PCI for STEMI from 2006 to 2013 in France, Israel, or the U.K.
Failed PCI occurred in 11% of patients, and namely due to distal embolization, coronary dissection, or inability to pass the wire through the thrombus. Moreover, there was a 3% rate of complicated PCI procedures; most cases involved cardiac arrest during the intervention as a result of refractory cardiogenic shock, ventricular fibrillation, or asystole.
The investigators noted that they were dealing with a highly selected group of nonagenarians, and thus the findings may not be generalizable.
“In our series, all patients presented with thoracic symptoms (acute chest pain and/or shortness of breath), which may be due to a selection bias. … As expected in this population, the majority in our cohort had multivessel coronary disease and mild-to-severe altered left ventricular dysfunction. The prevalence of presentation in Killip class III and IV was high, >30% in our series,” they wrote.
Additionally, most patients were female (62%) and 21% of the study group presented with cardiogenic shock.
P2Y12 inhibitors were given to 97% of the patients, and 90% received heparin. “Despite intensive antiplatelet and anticoagulant therapy, major or clinically relevant bleeding events were recorded in only six patients (4%) during in-hospital follow-up,” Helft and colleagues noted, suggesting that “the high rate of procedures conducted through the transradial approach may explain the low rate of access site bleeding complications.”
Relatively longer survival over follow-up were observed for men (49.6% versus 32.0% for women, log-rank P=0.039) and those with non-anterior STEMI (53.3% versus 26.7%, log-rank P=0.002).
On multivariable adjustment, female sex remained a predictor of early mortality in the nonagenarian population (hazard ratio 1.72, 95% CI 1.08-2.77).
“The main limitation of this study is that there is no comparison group, such as nonagenarians with STEMI who were not managed with primary PCI,” according to the authors. “This may be problematic because the study cohort appears to be highly selected with remarkably low comorbidity profile. As our study is retrospective and nonrandomised, it is not possible to draw definite conclusions over the absolute benefit of primary PCI.”
Another limitation was the lack of functional outcomes data, Helft’s group acknowledged.
“The main issue with the management of nonagenarians with STEMI is case selection,” Yudi told MedPage Today. “That is what could potentially change practice.”
“How did the interventionalist decide who they took to the lab? It is essential to review those who did not go to the lab. Perhaps there is a subset of patients who we are under-treating based on age and co-morbidities even though they have good cognitive and functional capacity.”
The study was funded by a French Federation of Cardiology fellowship grant.
Helft reported no relevant relationships with industry.
http://heart.bmj.com/content/early/2016/07/13/heartjnl-2015-308905.abstract Petroni T, et al “Primary percutaneous coronary intervention for ST elevation mycardial infarction in nonagenarians” Heart 2016; DOI: 10.1136/heartjnl-2015-308905.