Editorial Comment

Percutaneous CoronaryInterventions in the Elderly: Justthe Tip of the Iceberg

David A. Clark, MD

Division of Cardiology,Stanford University School of Medicine,Stanford, California

The article by Assali et al. [1] at the University of Texasnicely emphasizes the common experiences shared by mostinterventional cardiologists. In the elderly patient, particu-larly if the definition is over 75 years of age, there are morecomplications with percutaneous coronary intervention pro-cedures, as there are with almost any other medical proce-dure performed on the heart (coronary artery bypass sur-gery, valve replacement, etc.) or any other aging organsystem in other medical and surgical disciplines.

It is not surprising that Nasser et al. [2] found lesscomplications in his study using age 65 as the aged param-eter than did De Gregoria et al. [3] in his group of elderlypatients using age 75 as the numerical definition of old.Simple observation of one’s patient population through theyears emphasizes what a difference 10 years makes at anyage, but particularly in the advanced-age group.

The patient demographics in the article by Assali et al.[1] reveal the reasons for the expectations for morecomplications as patients age. The dramatic difference inpreponderance of females to males in the over-75 agegroup reflects the common knowledge that females livelonger and the number of females available to contractcoronary occlusions is greater than males. A higher in-cidence of hypertension, peripheral vascular disease, andprevious strokes reflects the relentless aging of arteriesthat we have come to expect. The higher incidence ofelevated cholesterol in the younger set perhaps reflectsmore aggressive medical treatment (or acceptance oftreatment) in the older set. Since all of these patients hadPCI in the current study, it would appear that those in theyounger set who had previous PCI want to stick with itand those in the older set who had a higher frequency ofbypass surgery want to try something less invasive.

With this knowledge, and even with the recognizedhigher incidence of complications, there can only be in-creased numbers of percutaneous coronary interventions inthe elderly in the future. The average age of those greaterthan 75 (79.6 in this current study) will surely increase wellinto the mid-80s over the next 10 years. This means yet

older arteries and more complications—but still preferableto the trauma of more invasive methods of repair or simplyallowing nature to take its course. This latter alternativeshould be of great concern to all physicians. Will someinsurance companies refuse to pay for stents in patients overa certain age? By controlling the purse strings will insurancecompanies mandate the style of stent to be used (the lessexpensive, noncoated model for example)?

In my practice, I recently placed stents in a witty,intelligent, fully functional 94-year-old man with unsta-ble angina and nitroglycerin intolerance who requiredmultiple emergency room visits and hospital admissionsbefore he was finally referred for invasive assessment.Will a patient like this delightful, deserving gentlemanqualify for future mandated criteria for treatment?

Over the past 10 years, we have seen that insurancecompanies can and do limit procedures (ad hoc angioplas-ties) and innovative techniques that are in the patient’s bestinterest (peripheral closure devices) by either reducing pay-ment to physicians and hospitals or not paying at all.

Using the political clout of various cardiology organi-zations (the Society for Cardiac Angiography and Inter-ventions, the American College of Cardiology) and non-cardiologic organizations (AARP), we must be ready toprotect the elderly patients to have the best, and leastinvasive, treatment for coronary artery disease. Eventhough the slightly higher complication rate is knownand published, it must be viewed in relation to the com-plications that would occur in both suffering and lifestyleif either more invasive procedures or benign neglect areconsidered as alternatives.

REFERENCES

1. Assali AR, Moustapha A, Sdringola S, et al. “The dilemma ofsuccess”: percutaneous coronary interventions in patients � 75years of age—successful but associated with higher vascular com-plications and cardiac mortality. Cathet Cardiovasc Intervent 2003;59:195–199.

2. Nasser TK, Fry ET, Annan K. Khatib Y, Peters TF, Van Tassel J, OrrCM, Waller BF, Pinto R, Pinkerton CA, Hermiller JB. Comparison ofsix-month outcome of coronary stenting in patients �65, 65–75, and�75 years of age. Am J Cardiol 1997;80:998–1001.

3. De Gregoria J. Kobayashi Y, Albiero R, Reimers B, DiMario C,Finci L, Colombo A. Coronary artery stenting in the elderly:short-term outcome and long-term angiographic and clinical fol-low-up. Am Coll Cardiol 1998;32:577–583.

DOI 10.1002/ccd.10562Published online in Wiley InterScience (www.interscience.wiley.com).

Catheterization and Cardiovascular Interventions 59:200 (2003)

© 2003 Wiley-Liss, Inc.