April 25, 2019
By Reuters Staff
NEW YORK (Reuters Health) - The use of percutaneous coronary intervention (PCI) after acute myocardial infarction is increasing in the elderly, and appears to boost survival even in patients 75 and older, according to a new study.
Adults aged 75 and older are a fast-growing demographic, expected to make up 11.5% of the U.S. population by 2050. Yet relatively little is known about whether PCI is beneficial in these patients.
"We know that PCI is safe, feasible and improves overall survival and well-being in younger adults who have a heart attack," study author Dr. Abdulla A. Damluji of Johns Hopkins University School of Medicine in Baltimore, Maryland, said in a news release.
"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," said Dr. Damluji.
As reported online April 23 in Circulation, Dr. Damluji and colleagues studied medical records of close to 470,000 patients aged 75 and older who were admitted to U.S. hospitals with a first MI from 2000 to 2016. Thirty-four percent were "young-old" (aged 75 to 79 years), 30% were "middle-old" (80 to 84) and 36% were "old-old" (85+).
Among the key findings:
- "Old-old" patients were most likely to have comorbid conditions on admission for first MI and were most likely to die in the hospital versus the "young-old" (13% vs. 8%).
- PCI for acute MI was performed in 38% of the young-old group, 33% of the middle-old group and 20% of the old-old group.
- PCI use among the old-old first-time MI patients increased sharply over time from 10% in 2000 to 25% in 2016, and the risk of death for these patients fell over time, from 17% in 2000 to 11% in 2016.
- In the young-old group, there was a significant reduction in overall mortality (odds ratio, 0.47) in those who had PCI relative to those who did not. The OR with PCI was 0.51 in the middle-old and 0.58 in the old-old.
"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," Dr. Damluji said in the release.
"Determining through a futility assessment when a procedure should not be done remains a critical challenge," added senior author Dr. Mauro Moscucci, chairman of Medicine at Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute. "Futile procedures are procedures that are not expected to change the outcome. They can even result in worse outcomes due to unexpected complications."
The authors caution that this is observational data. "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," said Dr. Damluji.
The study was funded by The Johns Hopkins University Claude D. Pepper Older Americans Independence Center, National Institute on Aging and the Jane and Stanley F. Rodbell family in support of geriatric cardiology research at Sinai Hospital of Baltimore.
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