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Changing outcome of angioplasty in the elderly
R C Thompson1, D R Holmes, D E Grill
1Division of Cardiovascular Diseases, Mayo Clinic Jacksonville, Florida, USA.
Insights
Improved success rates in elderly percutaneous transluminal coronary angioplasty (PTCA) did not enhance long-term survival. Despite lower in-hospital complications, intermediate-term outcomes remained unchanged due to patient comorbidities.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Geriatric Cardiology
Background:
- Elderly patients face higher risks for procedure-related mortality and angina recurrence after coronary angioplasty.
- Recent trends suggest a potential decrease in angioplasty complication rates.
Purpose of the Study:
- To evaluate changes in in-hospital and intermediate-term posthospital outcomes for elderly patients undergoing percutaneous transluminal coronary angioplasty (PTCA).
- Comparison of outcomes between two distinct time periods: 1980–1989 and 1990–1992.
Main Methods:
- Retrospective analysis of 982 elderly patients (≥65 years) undergoing non-emergent PTCA from 1980–1989 (Group A).
- Comparison with 768 similar elderly patients who underwent PTCA from 1990–1992 (Group B).
- Assessment of in-hospital and intermediate-term (6 months, 1 year) posthospital outcomes, including technical success, complications, and event-free survival.
Main Results:
- Group B patients were older with higher comorbidity scores, more men, and a greater history of myocardial infarction and bypass surgery compared to Group A.
- Despite increased patient complexity, Group B demonstrated higher technical success rates (93.5% vs. 88.1%) and significantly lower in-hospital complication rates (death, emergency bypass, death/MI).
- Intermediate-term event-free survival rates at 6 months and 1 year were not improved in Group B compared to Group A; the combined 6-month event rate was equivalent.
Conclusions:
- While percutaneous transluminal coronary angioplasty (PTCA) in the elderly has seen improved technical success and reduced short-term complications in recent years, this has not led to better long-term event-free survival.
- Baseline patient characteristics and comorbidities remain significant determinants of intermediate-term outcomes in this high-risk population.
- Further strategies are needed to improve long-term prognoses for elderly patients undergoing PTCA.
Objectives:
This study sought to determine whether in-hospital and intermediate-term posthospital outcomes have changed in elderly patients undergoing percutaneous transluminal coronary angioplasty from the period 1980 through 1989 to the period 1990 through 1992.
Background:
Although elderly patients have a higher incidence of procedure-related deaths and late recurrence of angina after coronary angioplasty, recent complication rates for angioplasty seem to be lower.
Methods:
From 1980 to 1989, 982 patients > or = 65 years old underwent nonemergent coronary angioplasty (group A). They were compared with 768 similar patients who had coronary angioplasty from 1990 to 1992 (group B).
Results:
Patients in group B were older than those in group A and had a higher mean concomitant disease score, a higher proportion of men and a greater proportion of patients with a previous myocardial infarction and previous coronary artery bypass surgery. Despite the increased complexity of the group B cohort, procedural success rates were higher, and rates of important in-hospital complications were much lower than those in group A. For group A versus group B, respectively, the technical success rate was 88.1% versus 93.5% (p < 0.001), in-hospital death rate 3.3% versus 1.4% (p = 0.014), emergency bypass surgery rate 5.5% versus 0.65% (p < 0.001) and incidence of in-hospital death or myocardial infarction 6.3% versus 3.4% (p < 0.005). However, intermediate-term posthospital event-free rates in hospital survivors did not decrease. The rate of death or myocardial infarction at 6 months was 4.7% in group A versus 7.1% in group B (p < 0.05). Survival free of acute myocardial infarction, bypass surgery, repeat coronary angioplasty or severe angina at 1 year was 66.7% in group A versus 54.9% in group B (p < 0.001). The combined in-hospital death/myocardial infarction rate plus that for the first 6 months after hospital dismissal was essentially equivalent for the two groups (10.3% vs. 9.9%, p = NS).
Conclusions:
An increase in technical success rates and a reduction in short-term complication rates for coronary angioplasty in the elderly in recent years have not translated into an improved event-free survival rate, which continues to be influenced by important baseline characteristics of these high risk patients.