What’s Age Got to do with it? A Review of Contemporary Revascularization in the Elderly

Author(s): Sebastian Vandermolen , Jane Abbott , Kalpa De Silva .

Journal Name: Current Cardiology Reviews

Volume 11 , Issue 3 , 2015

Become EABM
Become Reviewer

Graphical Abstract:


Abstract:

Currently a quarter of all patients treated with percutanous coronary intervention (PCI) are aged >75 years, with this proportion steadily growing. This subset of patients have a number of unique characteristics, such as a greater number of cardiovascular risk factors and frequently a larger burden of coronary artery disease, when compared to younger patients, therefore potentially deriving increased benefit from revascularization. Nonetheless this population are also more likely to experience procedural complications, secondary to age-related physiological alterations, increased frailty and increased prevalence of other co-morbidities. This article reviews the various aspects and data available to clinicians pertaining to and guiding revascularization in the elderly, including the use of adjuvant pharmacotherapy, specific considerations when considering age-related physiology, and revascularization in acute coronary syndromes.

Keywords: Elderly, revascularization, pathophysiology.

[1]
Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics—2007 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2007; 115: e69–e171. Originally published online December 28, 2006. Accessed May 2014.
[2]
Alexander KP, Roe MT, Chen AY, et al. for the CRUSADE Investigators. Evolution in cardiovascular care for elderly patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative. J Am Coll Cardiol 2005; 46: 1479-87.
[3]
Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007; 116: 803-77.
[4]
Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, writing on behalf of the 2004 Writing Committee. Circulation 2008; 117: 296-329.
[5]
Singh M, Peterson ED, Roe MT, et al. Trends in the association between age and in-hospital mortality after percutaneous coronary intervention: National Cardiovascular Data Registry experience. Circ Cardiovasc Interv 2009; 2: 20-6.
[6]
Bauer T, Mollman H, Weidinger F, et al. Predictors of hospital mortality in the elderly undergoing percutaneous coronary intervention for acute coronary syndromes and stable angina. Int J Cardiol 2011; 151(2): 164-9.
[7]
Sangiorgi G, Rumberger JA, Severson A, et al. Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: a histologic study of 723 coronary artery segments using nondecalcifying methodology. J Am Coll Cardiol 1998; 31: 126-33.
[8]
Hsu JT, Kyo E, Chu M, et al. Impact of calcification length ratio on the intervention for chronic total occlusions. Int J Cardiol 2011; 150(2): 135-41.
[9]
Soon KH, Cox N, Wong A, et al. CT coronary angiography predicts the outcome of percutaneous coronary intervention of chronic total occlusion. J Interv Cardiol 2007; 20: 359-66.
[10]
De Felice F, Fiorilli R, Parma A, et al. Clinical outcome of patients with chronic total occlusion treated with drug- eluting stents. Int J Cardiol 2009; 132: 337-41.
[11]
Hsu JT, Tamai H, Kyo E, et al. Traditional antegrade approach versus combined antegrade and retrograde approach in the percutaneous treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv 2009; 74: 555-63.
[12]
Batchelor WB, Anstrom KJ, Muhlbaier LH, et al. Contemporary outcome trends in the elderly undergoing percutaneous coronary interventions: results in 7,472 octogenarians. J Am Coll Cardiol 2000; 36: 723-30.
[13]
Mari D, Mannucci PM, Copoola R, et al. Hypercoagulability in centenarians: the paradox of successful aging. Blood 1995; 85: 3144-9.
[14]
Zahavi J, Jones NA, Leyton J, et al. Enhanced in vivo platelet “release reaction” in old healthy individuals. Thromb Res 1980; 17: 329-36.
[15]
Terres W, Weber K, Kupper W, Bleifeld W. Age, cardiovascular risk factors and coronary heart disease as determinants of platelet function in men. A multivariate approach. Thromb Res 1991; 62: 649-61.
[16]
Lakatta EG. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part III: cellular and molecular clues to heart and arterial aging. Circulation 2003; 107: 490-7.
[17]
Acree LS, Killewich LA, Aston C, et al. Age-related influences on markers of inflammation and fibrinolysis [abstract]. FASEB J 2008; 22: 923-7.
[18]
Knight CJ, Panesar M, Wright C, et al. Altered platelet function detected by flow cytometry. Effects of coronary artery disease and age. Arterioscler Thromb Vasc Biol 1997; 17: 2044-53.
[19]
Vaughan L, Zurlo F, Ravussin E. Aging and energy expenditure. Am J Clin Nutr 1991; 53: 821-5.
[20]
Robert L. Aging of the vascular wall and atherogenesis: role of the elastin-laminin receptor. Atherosclerosis 1996; 123: 169-79.
[21]
Vestal RE, Wood AJ, Shand DG. Reduced β-adrenoceptor sensitivity in the elderly. Clin Pharmacol Ther 1979; 26: 181-6.
[22]
Haqqani HM, Kalman JM. Aging and sinoatrial node dysfunction: musings on the not-so-funny side. Circulation 2007; 115: 1178-9.
[23]
Mehran R, Aymong ED, Nikolsky E, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol 2004; 44: 1393-9.
[24]
Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146-56.
[25]
Buchner DM, Wagner EH. Preventing frail health. Clin Geriatr Med 1992; 8: 1-17.
[26]
Zhou S, Chen J, Xu RY, Wu HY. Factors associated with the use of percutaneous coronary intervention in elderly Chinese patients with a first ST elevated acute myocardial infarction. Patient Prefer Adherence 2014; 8: 257-62.
[27]
Santana J, Haft J, LaMarche N, et al. Coronary angioplasty in patients eighty years of age or older. Am Heart J 1992; 124: 13-8.
[28]
Peterson ED, Jollis JG, Bebchuk JD, et al. Changes in mortality after myocardial revascularization in the elderly. The national medicare experience. Ann Intern Med 1994; 121: 919-27.
[29]
Jeroudi M, Kleiman N, Minor S, et al. Percutaneous transluminal coronary angioplasty in octogenarians. Ann Intern Med 1990; 113: 423-8.
[30]
Singh M, Peterson ED, Roe MT, et al. Trends in the association between age and in-hospital mortality after percutaneous coronary intervention: National Cardiovascular Data Registry experience. Circ Cardiovasc Interv 2009; 2: 20-6.
[31]
Singh M, Peterson ED, Roe MT, et al. Trends in the association between age and in-hospital mortality after percutaneous coronary intervention: National Cardiovascular Data Registry experience. Circ Cardiovasc Interv 2009; 2: 20-6.
[32]
O’Gara PT, Kushner FG, Ascheim DD, et al. 2013. ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013. Published online, accessed May 12th 2014 at . http://circ.ahajournals. org/content/127/4/e362.full.pdf+html
[33]
Thiemann DR, Coresh S, Shulman SP, et al. Lack of benefit for intravenous thrombolysis in patients with myocardial infarction in patients who are older than 75 years. Circulation 2000; 101(19): 2239-46.
[34]
Mehta RH, Sadiq I, Goldberg RJ, et al. Effectiveness of primary percutaneous coronary intervention compared with that of thrombolytic therapy in elderly patients with acute myocardial infarction. Am Heart J 2004; 147(2): 253-9.
[35]
Mehta RH, Harjai KJ, Boura J, et al. Ischemia-driven target vessel revascularization after-primary percutaneous coronary intervention: patients at risk and their outcomes. J Interv Cardiol 2005; 18(3): 149-54.
[36]
Bueno H, Betriu A, Hersa M, et al. Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J 2011; 32(1): 51-60.
[37]
Skolnick AH, Alexander KP, Chen AY, et al. Characteristics, management and outcomes of 5557 patients age > or = 90 years with acute coronary syndrome: results from the Crusade initiative. J Am Coll Cardiol 2007; 49(17): 1790-7.
[38]
Rigattieri S, Cera M, Sciahbasi A, et al. Primary Percutaneous Coronary Intervention in Nonagenarians. J Invasive Cardiol 2013; 25(5): 242-5.
[39]
Khera S, Kolte D, Palaniswarmy C, et al. ST-elevation myocardial infarction in the elderly--temporal trends in incidence, utilization of percutaneous coronary intervention and outcomes in the United States. Int J Cardiol 2013; 168(4): 3683-90.
[40]
Li R, Yan BP, Dong M, et al. Quality of life after percutaneous coronary intervention in the elderly with acute coronary syndrome. Int J Cardiol 2010; 155: 90-6.
[41]
De Servi S, Cavallani C, Dellavalle A, et al. Non-ST-elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome. Am Heart J 2004; 147(5): 830-6.
[42]
Liistro F, Angioli P, Falsini G, et al. Early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome: comparison with younger patients regarding 30 day and long term outcome. Heart 2005; 91(10): 1284-8.
[43]
De Servi S, Cavallini C, Dellavalle A, et al. Non-ST-elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome. Am Heart J 2004; 147(5): 830-6.
[44]
Devlin G, Gore J, Elliott J, et al. Management and 6-month outcome in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes. Eur Heart J 2008; 29: 1275-82.
[45]
Scherff F, Vassalli G, Surder D, et al. The SYNTAX score predicts early mortality risk in the elderly with acute coronary syndrome having primary PCI. J Invasive Cardiol 2011; 23: 505-10.
[46]
TIME Investigators. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): A randomised trial. Lancet 2001; 358: 951-7.
[47]
McKellar SH, Brown MI, Frye RL, et al. Comparison of coronary revascularization procedures in octogenarians: a systematic review and meta-analysis. Nat Clin Pract Cardiovasc Med 2008; 5: 738-46.
[48]
Bauer T, Mollman H, Weidinger F, et al. Predictors of hospital mortality in the elderly undergoing percutaneous coronary intervention for acute coronary syndromes and stable angina. Int J Cardiol 2011; 151(2): 164-9.
[49]
Sillano D, Resmini C, Meligra E, et al. Retrospective multicenter observational study of the interventional management of coronary disease in the very elderly: the NINETY. Catheter Cardiovasc Interv 2013; 82(3): 414-21.
[50]
Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356(15): 1503-16.
[51]
Shaw LJ, Berman DS, Maron DJ, et al. for the COURAGE Investigators Optimal Medical Therapy With or Without Percutaneous Coronary Intervention to Reduce Ischemic Burden: Results From the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial Nuclear Substudy. Circulation 2008; 117: 1283-91.
[52]
Trikalminos TA, Alsheikh-Ali AA, Tatsioni A, et al. Percutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis. Lancet 2009; 373(9667): 911-8.
[53]
Harrington RA, Becker RC, Cannon CP, et al. Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest In: 2008. 133(6 Suppl): 670S- 707S
[54]
ESPRIT Investigators Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy. Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. Lancet 2000; 356(9247): 2037-44.
[55]
Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators.Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. N Engl J Med 1998; 338(21): 1488-97. [Erratum in: N Engl J Med 1998; 339]. (6): 415..
[56]
Mehta SR, Yusuf S, Peters RJ, et al. Clopidogrel in Unstable angina to prevent Recurrent Events trial (CURE) Investigators. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 2001; 358(9281): 527-33.
[57]
Berger PB, Bhatt DL, Fuster V, et al. Bleeding complications with dual antiplatelet therapy among patients with stable vascular disease or risk factors for vascular disease: results from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial. Circulation 2010; 121(23): 2575-83.
[58]
Angiolillo DJ. ADP receptor antagonism: what’s in the pipeline? Am J Cardiovasc Drugs 2007; 7(6): 423-32.
[59]
Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009; 361(11): 1045-57.
[60]
Sugidachi A, Ogawa T, Kurihara A, et al. The greater in vivo antiplatelet effects of prasugrel as compared to clopidogrel reflect more efficient generation of its active metabolite with similar antiplatelet activity to that of clopidogrel’s active metabolite. J Thromb Haemost 2007; 5(7): 1545-51.
[61]
Wiviott SD, Braunwald E, McCabe CH, et al. TRITON-TIMI 38 Investigators Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007; 357(20): 2001-15.
[62]
Erlinge D, Gurbel PA, James S, et al. Prasugrel 5mg in the very elderly attenuates platelet inhibition but maintains noninferiority to prasugrel 10mg in nonelderly patients:the GENERATIONS trial, a pharmacodynamics and pharmacokinetic study in stable coronary artery disease patients. J Am Coll Cardiol 2013; 62(7): 577-83.
[63]
Kimmelstiel C, Badar J, Covic L, et al. Pharmacodynamics and pharmacokinetics of the platelet GPIIb/IIIa inhibitor tirofiban in patients undergoing percutaneous coronary intervention: implications for adjustment of tirofiban and clopidogrel dosage. Thromb Res 2005; 116(1): 55-66.
[64]
Weintraub WS, Grau-Sepulveda MV, Weiss JM, et al. Comparative effectiveness of revascularization strategies. N Engl J Med 2012; 366(16): 1467-76.
[65]
McKellar SH, Brown ML, Frye RL, et al. Comparison of coronary revascularization procedures in octogenarians: a systematic review and meta-analysis. Nat Clin Pract Cardiovasc Med 2008; 5(11): 738-46.
[66]
Fajadet J, Chieffo A. Current management of left main coronary artery disease. Eur Heart J 2012; 33: 36-50.
[67]
Capodanno D, Stone GW, Morice MD, et al. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery in Left Main Coronary Artery Disease. J Am Coll Cardiol 2011; 58: 1426-32.
[68]
Capodanno D, Caggegi A, Capranzano P, et al. Comparative one-year effectiveness of percutaneous coronary intervention versus coronary artery bypass grafting in patients <75 versus ≥75 years with unprotected left main disease (from the CUSTOMIZE Registry). Am J Cardiol 2012; 110(10): 1452-8.
[69]
Hoebers LP, Claessen BE, Dangas GD, et al. Long-term clinical outcomes after percutaneous coronary intervention for chronic total occlusions in elderly patients (>/=75 years): five-year outcomes from a 1,791 patient multi-national registry. Catheter Cardiovasc Interv 2013; 82: 85-92.
[70]
Levine GN, Bates ER, Blankenship JC, et al. American College of Cardiology F, American Heart Association Task Force on Practice G, Society for Cardiovascular A and Interventions. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58: e44-e122.
[71]
De Belder A, de la Torre Hernandez JM, Lopez-Palop R, et al. XIMA Investigators.A prospective randomized trial of everolimus-eluting stents versus bare-metal stents in octogenarians: the XIMA Trial (Xience or Vision Stents for the Management of Angina in the Elderly). J Am Coll Cardiol 2014; 63(14): 1371-5.
[72]
Groeneveld PW, Matta MA, Greenhut AP, Yang F. Drug-eluting compared with bare-metal coronary stents among elderly patients. J Am Coll Cardiol 2008; 51(21): 2017-24.
[73]
Schoos MM, Dangas GD. MaXIMAl benefits in the elderly? J Am Coll Cardiol 2014; 63: 1376-7.
[74]
Dougles P, Brennan JM, Anstrom K, et al. Clinical Effectiveness of Coronary Stents in Elderly Persons. J Am Coll Cardiol 2009; 53(18): 1629-41.
[75]
Achenbach S, Ropers D, Kallert L, et al. Transradial versus transfemoral approach for coronary angiography and intervention in patients above 75 years of age. Catheter Cardiovasc Interv 2008; 72(5): 629-35.
[76]
He P, Yang Y, Hu F. Transradial versus transfemoral percutaneous coronary intervention in elderly patients: a systematic overview and meta-analysis. Chin Med J (Engl) 2014; 127(6): 1110-7.


Rights & PermissionsPrintExport Cite as

Article Details

VOLUME: 11
ISSUE: 3
Year: 2015
Page: [199 - 208]
Pages: 10
DOI: 10.2174/1573403X10666141020110122
Price: $58

Article Metrics

PDF: 25
HTML: 2