Heart vessel-clearing procedure can benefit some at age 90 and older

Heart vessel-clearing procedure can benefit some at age 90 and older

An old man walks with a cane on Mar 16, 2017 in Nantes, western France. (Photo: AFP/Loic Venance)

People in their nineties and older represent a tiny but growing fraction of patients who undergo a procedure called percutaneous coronary intervention (PCI) to clear blocked blood vessels in the heart, new research shows.

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 per cent of the group, but that proportion increased from 0.25 per cent in 2008 to 0.58 per cent in 2014.

Thirty days after the procedure, 10.6 per cent of the nonagenarians had died, compared to 1.4 per cent of the younger patients. Mortality one year after the procedure was 16.3 per cent versus 4.2 per cent, 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.

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.

Source: Reuters