PCI in Nonagenarians Rising as Focus Shifts to Frailty Over Age

In-hospital mortality, major bleeding, and vascular complications have all changed over time among patients in their 90s undergoing PCI, according to new data, lending support to the view that frailty—not age—should take precedence in evaluating patients for revascularization.

“This study provides a benchmark for the rate of in-hospital complications associated with PCI in nonagenarians presenting with ACS and stable ischemic heart disease,” write the study authors, led by Kashish Goel, MD (Mayo Clinic, Rochester, MN). “These data provide a starting point for discussions among patients, families, and physicians but may underestimate the true risks and benefits of PCI in nonagenarians previously not thought to be candidates for PCI.”

For the study, Goel and colleagues looked at more than 69,000 nonagenarians from the National Inpatient Sample who underwent PCI between 2003 and 2014. This population made up 0.9% of all PCIs performed in the United States during that period, rising from 0.6% in 2003-2004 to 1.4% in 2013-2014 (P for trend < 0.001). The proportion of patients in their 90s receiving PCI for STEMI (23.1% to 30.9%) or NSTE ACS (49.6% to 52.6%) rose over time, while the percentage with stable ischemic heart disease fell (27.3% to 16.5%; P for trend < 0.001 for all).

The primary endpoint of in-hospital mortality was 16.4%, 4.2%, and 1.8% after PCI for STEMI, NSTE ACS, and stable ischemic heart disease, respectively. On multivariate analysis, this endpoint did not change over the study period for patients with STEMI (OR 1.04; 95% CI 0.98-1.11) and NSTE ACS (OR 0.99; 95% CI 0.91-1.08) but increased for those with stable ischemic heart disease (OR 1.21; 95% 1.01-1.44). Bleeding and vascular complication rates either fell or remained stable in each subgroup, but notably the risk-adjusted incidence of stroke increased over time for patients with STEMI or stable ischemic heart disease.

“The present study adds to the previously published small studies and is the first study to date presenting outcomes and trends of PCI stratified by indication in a nationally representative cohort,” Goel and colleagues write. “In this largest study to date of approximately 70,000 PCI-related hospitalizations in nonagenarians, we found significant changes in the absolute rates of in-hospital mortality, major bleeding, vascular complications, and stroke from 2003 to 2014. These variations were most likely a result of worsening baseline clinical risk profile and procedural factors.”

Emphasis on Frailty

In an accompanying editorial, Aditya Mandawat, MD (Duke University Hospital, Durham, NC), and Anant Mandawat, MD (Emory University Hospital, Atlanta, GA), write that the study “does not provide additional insight into whether PCI is superior to optimal medical therapy in these patients.”

Further, “these data likely underestimate the mortality and complications associated with PCI and overestimate those associated with medical therapy (ie, selection bias). At best, all that can be said is that highly selected nonagenarians who are referred for PCI have better outcomes than nonselected nonagenarians who receive (perhaps nonoptimal) medical therapy,” they add.

However, Mandawat and Mandawat argue the study’s importance lies in its ability to demonstrate that there is “no explicit (chronological) age cutoff above which older adults should not be offered PCI,” thus placing more of an emphasis on patient frailty.

Commenting on the paper for TCTMD, Samin Sharma, MD (Mount Sinai Medical Center, New York), said the main message from the study is that frail patients “should not be treated with PCI, [but with] palliative care.” On the other hand, patients who aren’t frail “should be able to be treated [with PCI] with a very low complication in this day and age,” he said.

In agreement, Davide Presutti, MD (Ospedale Valduce, Como, Italy), who also was not involved in the study, told TCTMD in an email that “PCI in nonagenarians should be considered an excellent strategy for selected patients and, obviously, physicians should perform a multiparametric evaluation. Age is just one of the many parameters to consider. The concept of frailty encompasses most of them.”

He explained that his typical approach to examining nonagenarians for PCI first involves taking a careful history, paying particular attention to renal function, and then a conversation with the patient and family members “in order to understand what kind of daily life the subject keeps and to evaluate the mental state. At the same time, when clearly indicated, I explain the pros and cons of the PCI procedure with the relative risks. Finally, a shared decision is sought.”

Sharma, who had finished a case of PCI in a 98-year-old patient immediately before speaking with TCTMD, stressed that “rather than going with just the age, we have to have eyeball tests to look at the patient—if you think the patient is able to carry out their daily routine activity, that type of patient should undergo cardiac catheterization with a plan.”

‘Age Is Just a Number’

Future studies should look to “correlate the outcome of the octogenarian and nonagenarian in relation to frailty,” Sharma suggested. In the same way a high SYNTAX score dictates that a patient with multivessel disease should be treated with CABG, it would be preferable to have a reliable frailty index that could guide revascularization decisions for nonagenarians, he added. “The patient with a low frailty index should go for PCI. If a patient has a high frailty index in this age group, [he or she] should be just managed medically.”

The editorialists say that this could start happening sooner rather than later. “Over the past decade, it has become clear that frailty—a complex interplay of biological, cognitive, and social factors—is closely associated with adverse periprocedural outcomes in older adults,” they write. “Despite this, until recently, systemic assessments of frailty have been more routinely used before cardiac surgery or transcatheter aortic valve replacement than PCI. This may rapidly change with the upcoming iteration of the American College of Cardiology/Society for Cardiovascular Angiography and Interventions CathPCI registry, which includes a standardized assessment of frailty.”

Presutti said he would also like to see studies looking at dual antiplatelet therapy in nonagenarians, as its management “plays an important role in the mid- and long-term prognosis of these patients.”

Ultimately, “age is just a number when it comes to PCI because there is 90 and then there is 90,” Mandawat and Mandawat conclude. “How successful we are at distinguishing the two is likely to have a major impact on the clinical care of our older patients.”