Abstract
Background
Preliminary study to assess the risk profile and outcomes of patients aged over 90 years at the time of percutaneous coronary intervention.
Methods
A database search was performed to identify patients 90 years or over at the time of percutaneous coronary intervention. Risk profile scores (Charlson Comorbidity Index, SYNTAX, Logistic clinical SYNTAX, New York PTCA score and frailty indices) were evaluated on 24 consecutive patients in order to determine the best predictor for survival. Between both groups (survivors and non-survivors) unpaired Student’s t-test was used to determine statistical significance.
Results
The New York PTCA score was significantly higher in those patients that died in hospital (n = 5) when compared to those who survived to discharge (n = 19) (NY PTCA score of 20.9 ± 5.4 vs. 4.5 ± 0.8, p < 0.001) and this was also seen with mortality at 12 months. The level of co-morbidity (Charlson index) was similar in patients who died in hospital (n = 5) compared with those who survived to discharge (n = 19, Charlson comorbidity index of 3.4 ± 0.7 vs.3.9 ± 0.6, p = 0.70). This trend was also observed at 1 year. The average level of frailty (by the CSHA Clinical Frailty Scale), SYNTAX score and logistic clinical SYNTAX were not significantly different between the two groups both at discharge and at 12 months. Choosing an arbitrary New York PTCA score of 9%, nearly two thirds of patients above this level died, whereas no patient below this level of risk died in hospital.
Conclusion
This small observational study found that nonagenarians who underwent PCI had relatively low comorbidity and SYNTAX scores. The specific coronary intervention (New York PTCA) risk score appears to have more predictive power in this small group of patients than the other three scores. Crucially, the factors that determine risk by New York PTCA score – haemodynamic instability, shock, pulmonary oedema, renal failure, etc. – are commonly encompassed by an “end-of-bed” assessment of the patient and these patients that pass this test ought not to be denied PCI on the basis of their advanced years.
Risk scores are used for a variety of purposes in the stratification of cardiovascular disease. They can be used at presentation to identify those at risk of early complications and those that would benefit from early aggressive therapy (e.g. GRACE, TIMI); they can be used to assess anatomy at angiography in a standardised way (e.g. SYNTAX). Finally, risk scores are available to assess the risk of surgery (EUROscore) or percutaneous coronary intervention (PCI), e.g. the New York PTCA score, in a given patient at a given time. These risk scores are validated for their individual purposes within a specific population. As our population ages, such tools must be revalidated to ensure they accurately assess the population concerned. Very few trials include patients of advanced age, yet these patients frequently present with acute coronary syndromes and, increasingly, are taken for angiography and PCI. There is a paucity of data on the risks and benefits of invasive management in the very elderly, especially those aged 90 years or over. This is an interesting group of patients who present a moral dilemma over whether invasive management is in their best interests. There may be a tendency to prejudge on the basis of age alone, which can be unfounded. In this letter, we discuss these issues in the light of our recent experience in this age group.
1
Methods
Our database of recent PCI procedures was searched in order to identify patients aged 90 years or over. 24 consecutive patients were identified, of whom 2 patients had multiple staged procedures, within a median timeframe of 2 years. Baseline characteristics are given in Table 1 . Records were reviewed in order to retrospectively perform scoring for comorbidity (using the Charlson comorbidity index ), anatomy (SYNTAX score ) anatomy with clinical variables (logistic clinical SYNTAX score ), and risk of coronary intervention (New York PTCA score ). SYNTAX scores were determined by a trained operator and confirmed with a second trained operator. Frailty was measured using the Canadian Study of Health and Aging (CSHA) Score . Figures are expressed as Mean ± SEM. Groups were compared using two-tailed Student’s t-test, with a p -value < 0.05 considered statistically significant.
| Age | 91.6 ± 0.4 years | |
| Gender | 11 F/13 M | |
| Presentation | STEMI | 13 |
| NSTEMI | 8 | |
| Unstable Angina | 2 | |
| Elective PCI | 1 | |
| Ejection fraction (%) | 43 ± 3 % | |
| Estimated glomerular filtration rate (mL/min) | 61 ± 4 mL/min | |
| Renal failure (Cr > 2.5 mg/dL) | 2/24 (8%) | |
| Haemodynamic instability | 3/24 (13%) | |
| Pulmonary edema | 9/24 (38%) | |
| Died in hospital | 5/24 (21%) | |
| Survived < 1 year | 10/24 (42%) | |
2
Results
5 patients out of a total of 24 died in hospital (21%). Additionally, 5 patients died within the year following initial presentation (21%). The New York PTCA score was significantly higher in those patients that died in hospital ( n = 5) when compared to those who survived to discharge from hospital ( n = 19); (NY PTCA score of 20.9 ± 5.4 vs. 4.5 ± 0.8, p < 0.001, Fig. 1 ). Similarly, the NY PTCA score was significantly higher when extending mortality to one year ( n = 10 [42%] vs. 14 [58%], NY PTCA score of 12.3 ± 3.9 vs. 4.8 ± 1.0, p = 0.04).
