Research Shows Survival Benefits of PCI for Very Old Patients Treated for First Heart Attack
April 23, 2019—The American Heart Association (AHA) announced findings that suggest that among heart attack patients ≥ 75 years of age, the oldest patients were less likely than younger patients to receive percutaneous coronary intervention (PCI); however, they were more likely to survive heart attacks if they had the procedure.
The analysis by Abdulla A. Damluji, MD, was published as a research letter online in Circulation: Cardiovascular Interventions. AHA noted that a limitation of the investigation is that it is not a clinical trial; rather, it shows an association between PCI and survival in very old adults > 85 years who were admitted with heart attack.
In the AHA press release, Dr. Damluji commented, “We know that PCI is safe, feasible, and improves overall survival and well-being in younger adults who have a heart attack. But older adults tend to have more complex medical needs and live with geriatric syndromes like frailty, multiple chronic conditions, cognitive impairment, and use multiple medications. Because of these intricacies, they are systematically excluded from clinical trials to test therapies including PCI. As such, the evidence on whether or not such treatment works in older adults has not been fully evaluated.”
The investigators evaluated medical records of approximately 470,000 older patients admitted to hospitals in the United States with a first heart attack from 2000 to 2016. Patients were grouped by age as 75 to 79 years (young-old), 80 to 84 years (middle-old) and ≥ 85 years (old-old).
As summarized by AHA, the investigators found:
- Patients in the old-old group were most likely to have other diseases when admitted for a first heart attack and also were most likely to die in the hospital compared with the young-old group (13% vs 8%)
- PCI was performed in 38%, 33%, and 20% of patients in the young-old group, middle-old, and old-old groups, respectively.
- PCI use among old-old first-time heart attack patients increased over time from 10% in 2000 to 25% in 2016, and risk of death decreased over time from 17% in 2000 to 11% in 2016.
- There was a 53% reduction in overall death among the young-old patients receiving PCI ompared to young-old patients who did not have PCI. The reduction in death with PCI was 49% among middle-old patients and 42% among old-old patients. Thus, for every 1,000 cases, lives were saved for 49 young-old patients, 53 middle-old patients, and 54 old-old patients.
Dr. Damluji stated, “We are attempting PCI in the very old patient population more and more over time, and even though this is a complex patient population and PCI is an invasive intervention, it appears that the life-saving benefit is substantial.”
Mauro Moscucci, MD, the senior investigator of the study commented in the AHA announcement, “Determining through a futility assessment when a procedure should not be done remains a critical challenge. Futile procedures are procedures that are not expected to change the outcome. They can even result in worse outcomes due to unexpected complications.”
Dr. Damluji added, “In order to have a sound conclusion about the effectiveness of PCI in this population, future clinical trials should enroll older adults even if they have complexities such as frailty, multiple chronic conditions cognitive dysfunction, and multiple medications.”