Summary
Background
Elderly patients are increasingly referred for complex percutaneous coronary interventions (PCI), including recanalization of chronic total occlusion (CTO).
Aims
To assess the feasibility, safety and clinical benefits associated with CTO-PCI in elderly patients.
Methods
Consecutive patients ( n = 356) who underwent CTO-PCI in our institution between January 2008 and December 2011 were prospectively included. The short-term outcomes of CTO-PCI were assessed by comparing the rates of successful recanalization and postoperative complications in patients aged ≥75 years and those <75 years. The clinical effect of successful recanalization was evaluated in a 20-month follow-up analysis in patients ≥75 years.
Results
Although patients ≥75 years ( n = 93) had more complex coronary artery disease, the procedural success rate was similar to that in younger patients (78.2% vs. 74.3%, respectively; P = 0.41). Postoperative complications were more frequent in older patients (5.4% vs. 0.4%; P = 0.005). Major adverse cardiac event-free survival analysis at 20 months revealed that successful revascularization was indicative of a better prognosis in older patients (hazard ratio: 0.43, 95% confidence interval: 0.19–0.96; P = 0.039).
Conclusion
Elderly patients have more complex coronary disease and are at a higher risk of postoperative complications. Nevertheless, we observed a similar success rate for CTO-PCI in elderly patients as for younger patients. Successful CTO recanalization improved the event-free survival rate at 20 months. Thus, CTO-PCI constitutes an alternative strategy for treating selected elderly patients.
Résumé
Contexte
Les patients âgés sont de plus en plus fréquemment adressés pour angioplastie de lésions coronaires complexes comme les occlusions coronaires chroniques (CTO).
Objectifs
Évaluer la faisabilité, la sécurité et l’impact pronostique d’une tentative d’angioplastie de CTO au sein d’une population de patients âgés.
Méthodes
Nous avons inclus les 356 patients consécutifs ayant bénéficié d’une angioplastie de CTO dans le CHU de Rangueil entre janvier 2008 et décembre 2011. À court terme, la faisabilité et la sécurité des procédures ont été évaluées en comparant le taux de succès et le taux de complication obtenus à 30 jours chez les patients de plus et de moins de 75 ans. Chez les patients ≥ 75 ans, l’impact pronostique du succès de la revascularisation a été évalué par une analyse de la morbi-mortalité à 20 mois.
Résultats
Le taux de succès des procédures d’angioplastie de CTO n’était pas significativement différent chez les patients ≥ 75 ans ( n = 93) et < 75 ans (74,3 % vs 78,2 % ; p = 0,41). Les complications post-angioplastie étaient néanmoins plus fréquentes dans le groupe ≥ 75 ans (5,4 % vs 0,4 % ; p = 0,005). À 20 mois, un succès de revascularisation de la CTO améliore le pronostic des patients âgés en réduisant le taux d’événements cardiovasculaires majeurs (HR : 0,43 ; IC 95 % : 0,19–0,96 ; p = 0,039) mais sans améliorer significativement la survie.
Conclusion
L’angioplastie des CTO est une stratégie de revascularisation qui peut raisonnablement être proposée aux patients âgés afin d’améliorer leur pronostic cardiovasculaire à moyen terme.
Background
Life expectancy has increased in recent decades, in part due to medical advances. As a result, more elderly patients are being referred to cardiologists for treatment of coronary artery disease (CAD), but the optimal management in those aged 75 years and older is debated. Indeed, the benefits of aggressive revascularization in elderly patients have been poorly investigated in randomized trials, and numerous studies have reported a higher risk of postoperative complications and lower procedural success rates with percutaneous coronary intervention (PCI) in the elderly. Techniques have improved, however, and evidence from more recent studies has suggested that elderly patients could, paradoxically, benefit more than younger patients from appropriate interventional revascularization . In clinical practice, older patients still have the lowest rates of revascularization and this is especially true for elderly patients with chronic total coronary occlusion (CTO). Indeed, studies have shown that because of the lower success rates of recanalization (60–70%), a minority of patients with CTO (8–15%) are referred for PCI .
The prevalence of CTO rises with age and can affect more than 30% of older patients suspected of having myocardial ischaemia , but there is no clear evidence on the best way to manage these patients. Indirect evidence from non-randomized studies suggests that CTO-PCI could improve survival and relieve symptoms related to myocardial ischaemia , but there is a paucity of data describing CTO-PCI among the elderly. Moreover, most studies on elderly patients were carried out 10 years ago and do not take into account the recent technical improvements in CTO-PCI (including widespread use of drug-eluting stents and CTO-dedicated devices) that have probably improved the outcome of CTO-PCI in elderly patients .
The aim of our study was to develop a comprehensive single-centre registry including all patients undergoing CTO-PCI in our department, to evaluate the feasibility, safety and outcomes of CTO-PCI in the elderly population (≥75 years).
Methods
Population
All consecutive patients referred to the Rangueil University Hospital, Toulouse, France for PCI of a chronically occluded native coronary vessel between January 2008 and December 2011 were included in the registry. Patients were divided into two age groups (<75 and ≥75 years). A CTO was angiographically defined as a complete occlusion with no anterograde filling of the distal vessel within the occluded segment . The duration of occlusion was assessed by the clinical history and previous angiograms. All patients referred for PCI had myocardial viability in the territory of CTO and persistent symptoms related to ischaemia despite optimal medical therapy, or extensive silent myocardial ischaemia documented by stress imaging such as magnetic resonance imaging, scintigraphy or echocardiography. The exclusion criterion was an estimated CTO duration of <3 months.
Data on patient baseline characteristics, procedural details and in-hospital outcomes were collected from medical records and a database by a trained medical investigator. Quality controls were performed before analysis. Chronic pulmonary disease was defined as the long-term use of bronchodilators or steroids for lung disease and the EuroSCORE was calculated according to the EuroSCORE I additive scoring method. Creatinine clearance was calculated according to the Modification of Diet in Renal Disease formula. Moderate chronic kidney was defined as creatinine clearance between 30 and 59 mL/min and severe disease as creatinine clearance <30 mL/min. Symptoms suggestive of congestive heart failure were classified according to the New York Heart Association (NYHA) classification and symptoms of angina according to the Canadian Cardiovascular Society (CCS) classification. Left ventricular ejection fraction was evaluated by echocardiography, magnetic resonance imaging or ventriculography.
Procedures
Procedures were performed according to the operators’ standard practices via a radial or femoral approach, and a retrograde approach was used when required.
Procedural success was defined as the restoration of an anterograde flow, with thrombosis in myocardial infarction (TIMI) flow grade 2 or 3 and a residual stenosis of <30% on angiography.
End-points and follow-up
For in-hospital outcomes, major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of death, myocardial infarction or stroke. Haemorrhage was defined as a drop in haemoglobin >3 g/dL and acute renal failure as a >25% rise in creatinine within the first 48 hours following PCI . The performance of coronary artery bypass graft surgery within 30 days was also recorded. As described in the European guidelines, post-PCI myocardial infarction was defined as an association of suggestive symptoms or electrocardiographic changes with a significant elevation in troponin concentration .
For long-term outcomes, data were collected annually by an experienced investigator who contacted all patients for a telephone interview. To complete the follow-up quality control, medical records from cardiologists and general practitioners were also collected and the data compared against the case report forms. The benefits of revascularization were evaluated at 20 months by comparing event-free survival rates among older patients according to the initial procedural outcome. Events were then defined as death, myocardial infarction and a need for revascularization (PCI or coronary artery bypass graft surgery). Patients who underwent a successful second CTO-PCI attempt within 3 months after failure of the first procedure were followed up from the date of the second PCI. Planned second attempts on the same lesion within 3 months were not recorded as events in the failure group.
The study protocol was approved by our institutional review board and all patients provided informed consent.
Statistical analysis
All continuous variables are described as mean and standard deviation (SD) or median and interquartile range (IQR). Categorical variables are presented as proportions. In bivariate analysis, qualitative variables were compared using the chi-square test (or the Fisher’s exact test when necessary). Mean values of quantitative variables were compared using Student’s t test. The Shapiro-Wilks and the Levene’s tests, respectively, were used to test the normality of the variables’ distributions and the homogeneity of variances. A non-parametric Mann-Whitney test was performed when basic assumptions of the Student’s t test were not satisfied.
The association between patient baseline characteristics and the risk of a post-PCI event was assessed by multivariable logistic analysis. The model was built by applying a forward procedure. Included variables were selected based on the scientific literature. Continuous variables fulfilled log-linearity.
The cumulative survival of patients according to procedural outcome (success or failure) was determined by the Kaplan-Meier method and compared using the log-rank test. The relations between the patient baseline characteristics, procedural outcome and major adverse cardiac events (MACE; defined as acute coronary syndromes, cardiogenic shock, new percutaneous coronary revascularization or death) at 20 months were assessed using Cox proportional hazards regression analysis. The multivariable model was built by applying a forward procedure. Variables were included in the model if their P -value was <0.20 in the bivariate analysis or if they were clinically pertinent. All included variables met the hypothesis of risk proportionality. Continuous variables also fulfilled log-linearity. The final model was checked using the Cox-Snell residual test.
All statistical analyses were performed using STATA v11.2 (STATA Corporation, College Station, Texas). For all tests, a P -value of <0.05 was considered significant.
Results
Baseline characteristics
A total of 374 CTO-PCIs were performed in 356 patients. Ninety-three (26.1%) of the patients were ≥75 years old (median age: 80 years, IQR: 78–83). Medical history and prevalence of cardiovascular risk factors were broadly similar in the two age groups, but older patients appeared to be at higher risk of postoperative complications ( Table 1 ). Indeed, they tended to be referred more frequently for acute coronary syndromes (ACS) related to other lesions (40.9% vs. 30.4%; P = 0.07), and they had higher rates of chronic renal disease ( P < 0.001) and symptoms of congestive heart failure on admission ( P = 0.014). Angiographic findings revealed more complex and more extensive CAD in older patients: 55 (59%) had a CTO involving the left anterior descending artery and 78 (84%) had multivessel disease.
| Variable | ≤75 years ( n = 263) | ≥75 years ( n = 93) | P -value |
|---|---|---|---|
| Age (years) | 60.6 ± 9.1 | 80.5 ± 3.8 | |
| Men | 231 (87.8) | 68 (73.1) | 0.001 |
| Body mass index (kg/m 2 ) | 28 ± 5.3 | 26.3 ± 3.6 | 0.01 |
| Hypertension | 134 (50.9) | 70 (75.3) | <0.001 |
| Diabetes mellitus | 85 (32.3) | 37 (39.8) | 0.19 |
| Hypercholesterolaemia | 199 (75.7) | 59 (63.4) | 0.023 |
| Current smoking | 182 (69.2) | 34 (36.6) | <0.001 |
| Creatinine clearance (mL/min) | 80 ± 27 | 67 ± 26 | <0.001 |
| Moderate CKD | 41 (15.6) | 33 (35.5) | |
| Severe CKD | 10 (3.8) | 6 (6.5) | <0.001 |
| Family history of premature CAD | 80 (30.4) | 13 (14.0) | 0.002 |
| Medical history | |||
| Myocardial infarction | 134 (50.9) | 50 (53.8) | 0.64 |
| PCI | 116 (44.1) | 44 (47.3) | 0.59 |
| Stroke | 19 (7.2) | 9 (9.7) | 0.45 |
| CABG | 15 (5.7) | 17 (18.3) | <0.001 |
| Peripheral artery disease | 63 (23.9) | 23 (24.7) | 0.88 |
| Angina CCS ≥2 at admission | 105 (39.9) | 35 (37.6) | 0.75 |
| Congestive heart failure symptoms (NYHA class) | |||
| I | 144 (54.7) | 40 (43.0) | |
| II | 91 (34.6) | 31 (33.3) | |
| III | 18 (6.8) | 16 (17.2) | |
| IV | 10 (3.8) | 6 (6.5) | 0.016 |
| Chronic obstructive pulmonary disease | 22 (8.4) | 11 (11.8) | 0.32 |
| EuroSCORE | 3 (2–6) | 9 (7–10) | <0.001 |
| Acute coronary syndrome | 80 (30.4) | 38 (40.9) | 0.07 |
| Stable angina | 88 (33.5) | 29 (31.2) | 0.69 |
| Silent myocardial ischaemia | 86 (32.7) | 25 (26.9) | 0.30 |
| Left ventricular ejection fraction (%) | 51 ± 11 | 48 ± 14 | 0.07 |
| Target vessel | |||
| Interventricular artery | 98 (37.3) | 55 (59.1) | <0.001 |
| Left circumflex artery | 78 (29.7) | 29 (31.2) | 0.78 |
| Right coronary artery | 152 (57.8) | 42 (45.2) | 0.035 |
| Number of diseased vessels | |||
| 1 | 73 (27.8) | 15 (16.1) | 0.025 |
| 2 | 88 (33.5) | 25 (26.9) | 0.24 |
| 3 | 102 (38.8) | 53 (57.0) | 0.004 |
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