Massive Study Offers Snapshot of PCI Outcomes in Nonagenarians

Denver, CO—New research assessing trends and outcomes following PCI among nonagenarians supports the use of the therapy in patients regardless of their age.

The results, presented at a moderated poster session on Monday at TCT 2017, should remind physicians that age should not be a barrier when it comes to coronary disease amenable to PCI, said lead author Kashish Goel, MD (Mayo Clinic, Rochester, MN). “We should know that it is a viable [option], and we should not just be saying, “The patient is 90 years old, so we should not be doing this.’”

Nonagenarians represent a growing demographic: in the United States alone, over 5 million individuals are between 90 and 99 years old, with census data from 2000 to 2010 showing this is the fastest-growing age group above 65 years.

“This is an increasing population, so there will be an increasing need for PCI. We saw that 90 percent of the patients had known CAD in this group,” Goel said. “So because we are doing more PCIs in this group, I think it is important to highlight what’s happening and what can we do better.” Most of all, he added, “we should not be declining PCI to nonagenarians.”

The study is the largest of its kind, with a sample size of approximately 70,000 nonagenarians. Using the National Inpatient Sample, researchers gathered details on patients age 90 and older who had undergone PCI in the United States between January 1, 2003 and December 31, 2014.

During the course of the study, Goel et al observed several trends in risk factors. The incidence of comorbidities like peripheral valve disease, renal failure, heart failure, and hypertension increased, as did the practice of using certain technologies and techniques including multivessel PCI, drug-eluting stents, and mechanical circulatory support. Specifically, use of MCS from 3.8% to 5.7% over 12-year period.

Among nonagenarians undergoing PCI for acute coronary syndromes, the prevalence of cardiogenic shock increased over time, while vascular complications and major bleeding decreased.

Need to Get More ‘Granular’

Goel acknowledges that his study has some drawbacks, in that it is retrospective and does not include “detailed angiographic results” or long-term follow-up data.

Debabrata Mukherjee, MD (Texas Tech University Health Sciences Center, El Paso, TX), the panel moderator for Goel’s presentation, told TCTMD that because the study is based on NIS numbers, it is “very reflective of US practice.”

That said, he continued, “one of the limitations of that data set is that we might not have granular data. We might not have data on actual severity of lesions [and] we may not have data on the medical therapies. Maybe a more robust dataset will help us to answer the questions better.”

Over time, the mortality in these patients remains high, “which means that we have to do better [both] in evaluating appropriate medical therapy for these individuals and in improving our device technology,” Mukherjee said, adding, “They are fragile and they are much more sensitive to contrasts in medications, so we are doing better [than before], but we have to continue to do better and improve outcomes in these high-risk patients. “

Goel pointed out the nonagenarians are often excluded from clinical trials, yet practitioners still “apply the data from other patients” to the eldest individuals in their caseloads. Going forward, he continued, “We need to be more cognizant of what’s happening and do more studies in this age group,” particularly as more of these patients end up getting TAVR and other new therapies.