1. PCI IN ELDERLY
- DEV PAHLAJANI
MD,FACC,FSCAI
CHIEF OF CARDIOLOGY,
BREACH CANDY HOSPITAL,MUMBAI

2. ELDERLY POPULATION:
A GROWING GLOBAL CHALLENGE
• IN USA, 35 MILL…………….IN 2000
• 82 MILL…………………………. IN 2030
ABOVE 80 YRS. 9.3 MILLION TO DOUBLE BY 2030

3. GRACE: FOR HIGH RISK ACS
AGE
 18466 patients
 dynamic ECG changes
 +ve cardiac markers
 44% > 70 yrs.
 < 70 yrs.-10380
 70-80 - 5057
 80 + - 3029

4. DEFINITION OF ELDERLY
 NO UNIVERSALLY ACCEPTED DEFINITION
 WHO: 60 YRS.
 MOST US CLASSIFICATION 65 AND ABOVE
 GRACE ACS 70YRS.

5. Management and 6-month Outcomes in
Elderly and Very Elderly Patients with
High-Risk non-ST-elevation Acute Coronary
Syndromes:
The Global Registry of Acute Coronary
Events
Gerard Devlin, Joel M. Gore, John Elliott,
Namal Wijesinghe, Kim A. Eagle, Álvaro Avezum,
Wei Huang and David Brieger for the GRACE Investigators

6. Inhospital events for high-risk patients with
NSTE-ACS
<70 years (n = 10 380)
With PCI/CABG Without PCI/CABG
45% (n = 4612) 55% (n = 5694)
CHF/pulmonary oedema, n (%) 316 (6.9) 488 (8.6), P < 0.01
Recurrent ischaemia, n (%) 1169 (26) 1311 (23), P < 0.01
Major bleeding, n (%) 102 (2.2) 73 (1.3), P < 0.001
Stroke, n (%) 21 (0.4) 20 (0.4), P = 0.6
Death, n (%) 87 (1.6) 203 (2.9), P < 0.001
Eur. HJ 2008, 29, 1275

7. Inhospital events for high-risk patients with
NSTE-ACS
70–80 years (n = 5057)
With PCI/CABG Without PCI/CABG
35% (n = 1741) 65% (n = 3291)
CHF/pulmonary oedema, n (%) 243 (14) 623 (19), P < 0.0001
Recurrent ischaemia, n (%) 533 (31) 775 (24), P < 0.0001
Major bleeding, n (%) 57 (3.3) 89 (2.7), P = 0.25
Stroke, n (%) 22 (0.7) 16 (0.9), P = 0.3
Death, n (%) 95 (4.3) 262 (6.2), P < 0.001
Eur. HJ 2008, 29, 1275

8. Inhospital events for high-risk patients with
NSTE-ACS
>80 years (n = 3029)
With PCI/CABG Without PCI/CABG
21% (n = 620) 79% (n = 2390)
CHF/pulmonary oedema, n (%) 124 (20) 539 (23), P = 0.2
Recurrent ischaemia, n (%) 182 (29) 511 (22), P < 0.0001
Major bleeding, n (%) 43 (7.0) 80 (3.4), P < 0.0001
Stroke, n (%) 3 (0.9) 21 (0.5), P = 0.45
Death, n (%) 57 (7.0) 363 (11), P < 0.001
Eur. HJ 2008, 29, 1275

9. Reperfusion Therapy In Elderly Patients With Acute
Myocardial Infarction :
A Randomized Comparison Of Primary Angioplasty And
Thrombolytic Therapy
Menko-Jan de Boer, MD*, Jan-Paul Ottervanger, MD*,
Arnoud W.J van’t Hof, MD*, Jan C.A Hoorntje, MD*, Harry Suryapranata, MD*,
Felix Zijlstra, MD*, the Zwolle Myocardial Infarction Study Group
Zwolle, the Netherlands

10. Clinical Course of the Two Patient Groups
Angioplasty Streptokinase
(n 46) p Value (n 41)
Mortality in-hospital,
n (%) 3 (7) 0.07 8 (20)
Stroke, n (%) 1 (2) 0.34 3 (7)
Recurrent AMI, n (%) 1 (2) 0.01 6 (15)
Bleeding (noncerebral)
5 (11) 0.72 3 (7)
JACC 2002, 39, 1723

11. 100
90
Overall Survival (%) PCI
80 P = 0.04
70 STK
0 1 2
year
Overall survival for patients randomized for angioplasty treatment (solid line)
and thrombolysis Treatment (dotted line) during 24 6 months of follow-up
(p = 0.04, relative risk: 2.5, 95% confidence interval: 1.0 to 6.2).
JACC 2002, 39, 1723

12. 100
90
Survival free of reinfarction PCI
or stroke (%) 80
70
P = 0.003
60
STK
50
0
1 2
year
Overall survival free of recurrent infarction or stroke for patients randomized for
angioplasty treatment (dashed line) and thrombolysis treatment (doted line)
during 24 6 months of follow-up (p = 0.003, relative risk: 3.1, 95% confidence
interval: 1.4 to 7.0).
JACC 2002, 39, 1723

13. Six-month outcomes for high-risk patients with
NSTE-ACS
<70 years (n = 10 380)
With PCI/CABG Without PCI/CABG
45% (n = 4612) 55% (n = 5694)
Death, n (%) 74 (1.7) 191 (3.5), P < 0.0001
Myocardial infarction, n (%) 85 (2.2) 128 (2.9), P = 0.06
Stroke, n (%) 18 (0.4) 46 (0.9), P < 0.01
Triple endpoint, n (%) 170 (3.8) 337 (6.2), P < 0.0001
Re-admission for cardiac
695 (17) 842 (16), P = 0.7
event, n (%)
Eur. HJ 2008, 29, 1275

14. Six-month outcomes for high-risk patients with
NSTE-ACS
70–80 years (n = 5057)
With PCI/CABG Without PCI/CABG
35% (n = 1741) 65% (n = 3291)
Death, n (%) 50 (3.0) 268 (8.5), P < 0.0001
Myocardial infarction, n (%) 51 (3.5) 141 (5.4), P < 0.01
Stroke, n (%) 27 (1.7) 39 (1.3), P = 0.30
Triple endpoint, n (%) 118 (7.0) 415 (13), P < 0.0001
Re-admission for cardiac
275 (17) 647 (22), P < 0.01
event, n (%)
Eur. HJ 2008, 29, 1275

15. Six-month outcomes for high-risk patients with
NSTE-ACS
>80 years (n = 3029)
With PCI/CABG Without PCI/CABG
21% (n = 620) 79% (n = 2390)
Death, n (%) 69 (12) 420 (19), P < 0.0001
Myocardial infarction, n (%) 27 (5.2) 146 (8.1), P = 0.03
Stroke, n (%) 12 (2.2) 62 (3.1), P = 0.24
Triple endpoint, n (%) 98 (17) 564 (25), P < 0.0001
Re-admission for cardiac
128 (23) 531 (26), P = 0.1
event, n (%)
Eur. HJ 2008, 29, 1275

16. Six-month post-discharge outcomes in young, according
to those who did and did not undergo revascularization.
40
30 P<0.0001
Patients (%)
20 P<0.01 17 15
P<0.0001
10 3.8 6.2
1.7 3.5 2.2 2.9
0.4 0.9
0
Death MI Stroke Triple endpoint Re-admission
for cardiac
Revasc + Revasc - illness
Eur. HJ 2008, 29, 1275

17. Six-month post-discharge outcomes in elderly age
groups according to those who did and did not
undergo revascularization.
40
P<0.0001
30
Patients (%)
22
20 P<0.0001 P<0.01 17
13
10 8.5 7
3 3.5 5.4 1.7 1.3
0
Death MI Stroke Triple Re-admission
endpoint for cardiac
illness
Revasc + Revasc -
Eur. HJ 2008, 29, 1275

18. Six-month post-discharge outcomes in very elderly
age groups according to those who did and did not
undergo revascularization.
P<0.0001
40
P=0.03
P<0.0001
30 25 26
Patients (%)
23
19 17
20
12
10 8.1
5.2
2.2 3.1
0
Death MI Stroke Triple endpoint Re-admission
for cardiac
illness
Revasc + Revasc -
Eur. HJ 2008, 29, 1275

19. Optimal Medical Therapy With or Without
Percutaneous Coronary Intervention in
Older Patients With Stable Coronary Disease
A Pre-Specified Subset Analysis of the COURAGE
(Clinical Outcomes Utilizing Revascularization and Aggressive drug
Evaluation) Trial
• Koon K. Teo, MB, BCh, PhD*, Steven P. Sedlis, MD, William E.
Boden, MD,*, Robert A. O'Rourke, MD, David J. Maron, MD||, Pamela
M.Hartigan, PhD¶, Marcin
• Dada, MD#, Vipul Gupta, MBBS, MPH, John A. Spertus, MD, MPH**, William
J.Kostuk, MD, Daniel S. Berman, MD, Leslee J. Shaw, PhD, Bernard
R.Chaitman, MD||||, G.B. John Mancini, MD¶¶, William S. Weintraub, MD##
COURAGE Trial Investigators
JACC 2009, 54, 1303

20. COURAGE TRIAL
Primary and Secondary Outcomes by
Treatment Arm and Age Group
Age <65 Yrs (n = 1,381)
OMT PCI HR p Value
Outcome (n = 693) (n = 688) (95% CI)
Death 41 (6%) 25 (4%) 0.68 (0.42–1.10) 0.11
MI 76 (11%) 83 (12%) 1.12 (0.82–1.53) 0.44
Death/MI 110 (16%) 109 (16%) 1.01 (0.78–1.31) 0.93
Death/MI/stroke 115 (17%) 115 (17%) 1.02 (0.79–1.33) 0.86
ACS 85 (12%) 87 (13%) 1.03 (0.77–1.39) 0.83
JACC 2009, 54, 1303

21. COURAGE TRIAL
Primary and Secondary Outcomes by
Treatment Arm and Age Group
Age >65 Yrs (n = 904)
OMT PCI HR Interaction
Outcome
(n = 444) (n = 460) (95% CI) p Value p Value
Death 54 (12%) 57 (12%) 1.01 (0.69–1.46) 0.97 0.21
MI 52 (12%) 60 (13%) 1.14 (0.79–1.66) 0.48 0.95
Death/MI 93 (21%) 104 (23%) 1.10 (0.83–1.45) 0.51 0.66
Death/MI/stroke 99 (22%) 109 (24%) 1.08 (0.82–1.42) 0.58 0.77
ACS 40 (9%) 49 (11%) 1.19 (0.79–1.81) 0.41 0.58
JACC 2009, 54, 1303

22. Survival of Elderly Patients Undergoing
Percutaneous
Coronary Intervention for
Acute Myocardial Infarction Complicated by
Cardiogenic Shock
Han S. Lim, MBBS*,**, Omar Farouque, MBBS, FRACP, PhD, FACC*,, Nick
Andrianopoulos, MBBS, MBiostat, Bryan P. Yan, MBBS, FRACP,, Chris C.S. Lim,
MBBS||, Angela L. Brennan, RN, CCRN, Chris M. Reid, BA, MSc, DipEd, PhD, Melanie
Freeman, MBBS*, Kerrie Charter, RN, CCRN*, Alexander Black, MBBS, FRACP,,¶,
Gishel New, MBBS, FRACP, PhD, FACC||, Andrew E. Ajani, MBBS, FRACP, FJFICM,
MD,,, Stephen J. Duffy, MBBS, MRCP, FRACP, PhD#, David J. Clark, MBBS, FRACP*,*
on behalf of the Melbourne Interventional Group
JACC Intv. 2009, 2, 146

23. Clinical Outcomes : In-Hospital
Age ≥ 75 Years Age <75 Years p Value
In-hospital (n = 143)
Mortality 19 (42.2) 33 (33.7 0.33
Complications
Periprocedural MI 2 (4.7) 2 (2.1) 0.41
Emergency PCI 1 (2.3) 1 (1.0) 0.53
Unplanned CABG 1 (2.3) 4 (4.3) 1.00
Bleeding 4 (8.9) 3 (3.1) 0.21
Congestive heart failure 18 (40.0) 25 (25.5) 0.08
Renal failure 13 (28.9) 12 (12.2) 0.02
Stroke 1 (2.2) 2 (2.0) 1.00
JACC Intv. 2009, 2, 146

24. Clinical Outcomes : 30 Days
Age ≥ 75 Years Age <75 Years p Value
30 days (n = 141)
Mortality 19 (43.2) 35 (36.1) 0.42
MI 2 (4.5) 3 (3.1) 0.65
TVR 2 (4.5) 6 (6.2) 0.70
MACE 22 (50.0) 40 (41.2) 0.33
JACC Intv. 2009, 2, 146

25. Clinical Outcomes : One year
Age ≥ 75 Years Age <75 Years p Value
1 year (n = 117)
Mortality 20 (52.6) 37 (46.8) 0.56
Cardiac 17 (85.0) 34 (91.9) 0.65
Noncardiac 3 (15.0) 3 (8.1) 0.65
MI 2 (5.3) 3 (3.8) 0.66
TLR 3 (7.9) 5 (6.3) 0.71
TVR 3 (7.9) 6 (7.6) 0.96
MACE 24 (63.2) 42 (53.2) 0.31
JACC Intv. 2009, 2, 146

26. PCI IN AMI SHOCK
Kaplan-Meier Estimates of Cumulative 1-Year Survival
JACC Intv. 2009, 2, 146

27. PCI IN AMI SHOCK
Kaplan-Meier Estimates of Cumulative 1-Year Freedom From MACE
JACC Intv. 2009, 2, 146

28. PCI IN AMI SHOCK
Multivariate Analysis of In-Hospital Mortality
Variable Odds Ratio 95% CI p Value
Renal failure 3.41 1.21–9.63 0.02
IABP use 2.11 0.97–4.59 0.06
STEMI 0.55 0.22–1.38 0.20
Diabetes 1.63 0.70–3.76 0.26
Hypertension 1.59 0.69–3.63 0.27
Age ≥ 75 years 1.04 0.46–2.36 0.93
JACC Intv. 2009, 2, 146

29. Long-Term Paclitaxel-Eluting Stent
Outcomes in Elderly Patients
Daniel E. Forman, MD; David A. Cox, MD; Stephen G. Ellis, MD;
John M. Lasala, MD; John A. Ormiston, MD; Gregg W. Stone, MD;
Mark A. Turco, MD; Jeanne Y. Wei, MD; Anita A. Joshi, MD;
Keith D. Dawkins, MD and Donald S. Baim, MD
Circ Card. Vasc. Intv. 2009 2, 178

30. 5-year cumulative rates of death (upper left), MI
(upper right), Academic Research Consortium, definite/probable ST (lower left), and TLR
(lower right) for patients receiving PES in the randomized trials
Circ. Card. Vasc. Intv. 2009 2, 178

31. 5-year cumulative rates of death (upper left), MI (upper right), Academic Research
Consortium, definite/probable ST (lower left), and target lesion revascularization (TLR) (lower
right) for PES versus BMS in patients aged >70 years in the randomized trials
Circ. Card. Vasc. Intv. 2009 2, 178

32. TAKE HOME MESSAGE
 PCI results in elderly are comparable with younger population
due to improved tech. Hardware and des
 The results of PCI including multi site arterial involvement
have become acceptable
 Number of elderly is growing due to improved longevity

33. Thank you!!