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Outcome of Percutaneous Coronary Intervention During Non-ST-Segment-Elevation Myocardial Infarction in Elderly
Martin J Holzmann1,2, Anwar J Siddiqui1,2
1Department of Medicine Karolinska Institutet Stockholm Sweden.
Insights
Percutaneous coronary intervention (PCI) for elderly patients with non-ST-segment-elevation myocardial infarction and chronic kidney disease is underutilized but offers significant survival benefits across all kidney function levels. However, increased bleeding risk is noted with PCI in severe kidney disease.
Area of Science:
- Cardiology
- Nephrology
- Geriatrics
Background:
- Limited data exists on revascularization benefits in elderly non-ST-segment-elevation myocardial infarction (NSTEMI) patients with chronic kidney disease (CKD).
- CKD, defined by estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m², is common in elderly NSTEMI patients.
Purpose of the Study:
- To evaluate the survival benefit of percutaneous coronary intervention (PCI) in patients over 80 years old with NSTEMI and varying degrees of CKD.
- To assess the utilization rates of PCI in this specific patient population.
Main Methods:
- Retrospective analysis of 12,821 patients aged >80 with NSTEMI and CKD from the SWEDEHEART Registry (2011-2014).
- Cox regression and logistic regression models were used to analyze mortality, reinfarction, and bleeding risks, stratified by eGFR.
- Propensity score weighting was employed for sensitivity analysis.
Main Results:
- PCI utilization was lower in patients with lower eGFR (30-60 mL/min/1.73 m²: 22%; 15-<30 mL/min/1.73 m²: 10%) compared to those with eGFR >60 (36%).
- PCI was associated with a significantly lower risk of all-cause mortality across all eGFR groups (HRs ranging from 0.44 to 0.50).
- Patients with eGFR 15-<30 mL/min/1.73 m² undergoing PCI experienced a higher risk of bleeding.
Conclusions:
- PCI is underused in elderly NSTEMI patients with CKD.
- PCI appears to provide a survival advantage for elderly NSTEMI patients with CKD, irrespective of kidney function.
- Careful consideration of bleeding risk is warranted for PCI in patients with severe CKD (eGFR 15-<30 mL/min/1.73 m²).
Abstract:
Background There is a paucity of data on the benefit of revascularization by percutaneous coronary intervention (PCI) during non-ST-segment-elevation myocardial infarction in patients aged >80 years with concurrent chronic kidney disease. Methods and Results Patients aged >80 years with chronic kidney disease, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m2 with non-ST-segment-elevation myocardial infarction, during 2011 to 2014 in Sweden retrieved from the SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) Registry. Cox regression was used to estimate adjusted hazard ratios with 95% CIs for all-cause mortality in patients with PCI versus no PCI treatment, stratified for eGFR. Logistic regression was used to evaluate adjusted odds for reinfarction and bleeding during hospitalization. Propensity score weighting analysis was also done as sensitivity analysis. In total, 12 821 patients were included, of whom 47%, 45%, and 8% had an eGFR of >60, 30 to 60, and 15 to <30 mL/min per 1.73 m2, respectively. Patients with eGFR 30 to 60 and 15 to <30 mL/min per 1.73 m2, 22%, and 10%, respectively, underwent PCI, compared with 36% among patients with eGFR >60 mL/min per 1.73 m2. During a mean follow-up of 3.2 years, the absolute risk of death was 42%, 56%, and 76% in patients with eGFR >60, 30 to 60, and 15 to <30 mL/min per 1.73 m2, respectively. Patients who underwent PCI had a lower risk of death in all groups of eGFR (0.47 [95% CI, 0.42-0.53], 0.50 [95% CI, 0.45-0.56], and 0.44 [95% CI, 0.33-0.59], respectively). Patients with eGFR 15 to <30 mL/min per 1.73 m2 had a higher risk of bleeding with PCI. Propensity score weighting showed similar outcomes for mortality risk as the unweighted analysis in all the eGFR groups. Conclusions PCI is rarely used in non-ST-segment-elevation myocardial infarction elderly patients with chronic kidney disease, and it appears to offer a survival benefit.
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