Impact of frailty on outcomes of elderly patients undergoing percutaneous coronary intervention: A systematic review and metaanalysis

BACKGROUND Frailty is a common condition in elderly patients who receive percutaneous coronary intervention(PCI).However,how frailty affects clinical outcomes in this group is unclear.AIM To assess the link between frailty and the outcomes,such as in-hospital complic-ations,post-procedural complications,and mortality,in elderly patients post-PCI.METHODS The PubMed/MEDLINE,EMBASE,Cochrane Library,and Web of Science databases were screened for publications up to August 2023.The primary outcomes assessed were in-hospital and all-cause mortality,major adverse cardiovascular events(MACEs),and major bleeding.The Newcastle-Ottawa Scale was used for quality assessment.RESULTS Twenty-one studies with 739693 elderly patients undergoing PCI were included.Frailty was consistently associated with adverse outcomes.Frail patients had significantly higher risks of in-hospital mortality[risk ratio:3.45,95%confidence interval(95%CI):1.90-6.25],all-cause mortality[hazard ratio(HR):2.08,95%CI:1.78-2.43],MACEs(HR:2.92,95%CI:1.85-4.60),and major bleeding(HR:4.60,95%CI:2.89-7.32)compared to non-frail patients.CONCLUSION Frailty is a pivotal determinant in the prediction of risk of mortality,development of MACEs,and major bleeding in elderly individuals undergoing percutaneous coronary intervention.

Fragile hearts:Unveiling the crucial layers of frailty in elderly patients undergoing percutaneous coronary interventions

Wang and Liu's systematic review of frailty among elderly patients undergoing percutaneous coronary intervention(PCI)revealed that patients with frailty have significantly higher risks of all-cause and in-hospital death,major undesirable cardiovascular events,and major haemorrhage.Frailty is associated with adverse events,prolonged hospital stays,increased complications,and elevated mortality risk due to diminished physiological reserves.Integrating frailty into risk assessment tools is crucial,and gait speed has emerged as a key predictor of frailty.Recognizing the impact of frailty leads to personalized and informed decisionmaking,and frailty assessments should be performed.This holistic approach can inform tailored interventions,thereby optimizing outcomes for this vulnerable population undergoing PCI.

Research Progress on the Depression Status and Nursing Intervention in Patients after Percutaneous Coronary Intervention

Percutaneous coronary intervention(PCI)is an effective treatment method for myocardial ischemic necrosis.Postoperative depression caused by PCI stress will adversely affect the prognosis of patients.This article reviews the current status and influencing factors of postoperative depression after PCI and summarizes the corresponding nursing interventions,to provide a literature reference to implement effective nursing interventions for depressed patients after clinical PCI.

Homocysteine is associated with the progression of non-culprit coronary lesions in elderly acute coronary syndrome patients after percutaneous coronary intervention

Background The influence of homocysteine （Hcy） on the migration and proliferation of vascular smooth muscle cells has been well established. However, the impact of Hcy levels on the progression of non-culprit coronary lesions （NCCLs） is controversial. This study aims to evaluate whether the plasma level of Hcy is related to the progression of NCCLs after percutaneous coronary stent implantation in elderly patients with acute coronary syndrome （ACS）. Methods A total of 223 elderly patients （〉 65 years old） with ACS undergoing stent im- plantation and follow-up coronary angiography were enrolled. Laboratory determination comprised of blood sample evaluation for Hcy was carried out before baseline coronary intervention. The patients were classified into two groups according to the blood Hcy tertiles （〉 15 mmol/L or 〈 15 mmol/L）. Patients were followed up for 12.2 months. NCCL progression was assessed by three-dimensional quantitative coronary angiography. Results A significantly higher ratio of NCCL progression was observed in the group with baseline Hcy concentrations above 15 mmol/L compared to the group with concentrations below 15 mmol/L （41/127, 32.3% vs. 14/96, 14.6%, P = 0.002）. Multivariate Cox regression analysis showed that Hcy and diabetes mellitus were independent risk factors for NCCL progression. The crude haz- ard ratio （HR） of NCCL progression for Hcy level was 1.056 （95% CI： 1.01-1.104, P = 0.015）. The adjusted HR of NCCL progression for Hcy level was 1.024 （95% CI： 1.007-1.042, P = 0.007）. The adjusted HR of NCCL progression for diabetes mellitus was 1.992 （95% CI： 1.15-3.44, P = 0.013）. Conclusions Hcy is an independent risk factor for NCCL progression after 12 months of follow-up in elderly patients with ACS who has undergone percutaneous coronary stenting.

Safety and feasibility of transradial approach for primary percutaneous coronary intervention in elderly patients with acute myocardial infarction

Background Transradial coronary intervention has been widely used because of its effects in lowering the incidence of complications in vascular access site and improving patient satisfaction compared to the femoral approach. This study aimed to investigate the safety and feasibility of transradial approach for primary percutaneous coronary intervention （PCI） in elderly patients with acute myocardial infarction （AMI）. Methods A total of 103 consecutive elderly patients Cage 〉65 years） who were diagnosed as having AMI were indicated for PCI. Among them, 57 patients received primary PCI via the transradial approach （transradial intervention, TRI group）, and 46 underwent primary PCI via the transfemoral approach （transfemoral intervention, TFI group）. The success rate of puncture, puncture time, cannulation time, repeffusion time, the total time for PCI, the success rate of PCI, the use rates of temporary pacemaker and intra-aortic balloon pump （IABP）, and the total length of hospital stay of the patients in the two groups were compared. After the procedure, vascular access site complications and major adverse cardiovascular events （MACE） in the two groups in one month were observed. Results The success rates of puncture （98.2% vs 100.0%） and PCI （96.5% vs 95.7%） for the patients in the TRI and TFI groups were not statistically significant （P〉0.05）. The puncture time （（2.4±1.1） vs （2.0±0.9） minutes）, cannulation time （（2.7±0.5） vs （2.6±0.5） minutes）, reperfusion time （（16.2±4.5） vs （15.4±3.6） minutes）, total time of the procedure （（44.1±6.8） vs （41.2±5.7） minutes）, use rates of temporary pacemaker （1.8% vs 2.2%） and IABP （0 vs 2.2%） in the two groups were not statistically significant （P〉0.05）, but the hospital stay of the TFI group was longer than that of the TRI group （（10.1±4.6） vs （7.2±2..6） days, P〈0.01）. A radial occlusion was observed in the TRI group, but no ischemic syndrome in hand. In the TFI group, 4 patients had hematosis, 1 had pseudoaneurysm, and 1 had major bleeding. Statistical significance in vascular access site complications was seen in the two groups （1.8 % vs 13.1%, P〈0.05）. Three patients died in the two groups respectively in one month, and there was no statistical significance in MACE in the two groups （5.3% vs 6.5%, P〉0.05）. Conclusion The transradial approach for primary PCI is safe and feasible for elderly patients with AMI.

Relationship between red blood cell distribution width and intermediate-term mortality in elderly patients after percutaneous coronary intervention

Background Large-scale clinical research on the relationship between red blood cell distribution width （RDW） and intermediate-term prognosis in elderly patients with coronary artery disease （CAD） is lacking. Thus, this study investigated the effects of RDW on the intermediate-term mortality of elderly patients who underwent elective percutaneous coronary intervention （PCI）. Methods Data from 1891 patients 〉 65 years old underwent elective PCI from July 2009 to September 2011 were collected. Based on preoperative median RDW （12.3%）, the patients were divided into two groups. The low RDW group （RDW 〈 12.3%） had 899 cases; the high RDW group （RDW 〉 12.3%） had 992 cases. The all-cause mortality rates of the two groups were compared. Results Patients in the high RDW group were more likely to be female and accompanied with diabetes, had lower hemoglobin level. The mean follow-up period was 527 days. During follow-up, 61 patients died （3.2%）. The postoperative mortality of the high RDW group was significantly higher than that of the low RDW group （4.3% vs. 2.0%, P = 0.004）. After adjusting other factors, multivariate Cox regression analysis revealed that preoperative high RDW was significantly associated with postoperative all-cause mortality （hazard ratio： 2.301, 95% confidence interval： 1.106-4.785, P = 0.026）. Conclusions Increased RDW was an independent predictor of the increased intermediate-term all-cause mortality in elderly CAD patients after elective PCI.

Risk factors of acute myocardial infarction following primary percutaneous coronary intervention among elderly patients

Background and Objective Large randomized controlled trials have demonstrated that percutaneous coronary intervention （PCI） with the routine use of drug-eluting stents is safe and effective, however, the patients older than 75 years undergoing PCI are at increased risk for major adverse cardiac events, so that the patients are usually excluded from this trial. The aim of the present study was to assess the early clinical outcome and risk factors in old patients with acute ST elevation myocardial infarction （STEMI） following primary PCI. Methods We analyzed the outcome after stenting in 136 patients older than 60 years in our coronary care unit with acute STEMI, and the patients were further classified in 2 age groups： patients≥75 years and 〈75 years. Results Though the older group had a higher prevalence of adverse baseline characteristics and lower final TIMI flow than those of the younger, the procedural success had no difference between two groups. The main adverse clinical events （MACE） for the old group was a little higher comparing with the younger in 12-month following up. Conclusions Our study suggest that drug-eluting stent implantation in elderly patients with acute ST elevation myocardial infarction has high initial procedural success rates despite having more severe baseline risk characteristics, and to shorten the time form symptom onset to PCI and improve final TIMI flow strategy may decrease MACE among old patients following PCI（J Geriatr Cardio12009; 6：67-70）.

A comparative study on transradial vs transfemoral artery access for primary percutaneous coronary intervention in patients with acute myocardial infarction

Objective Comparative study on the feasibility,safety and outcome of transradial artery and transfemoral artery access for primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction(AMI).Methods Two hundred and eight patients with AMI episoded within 12 hours, male 159, female 49, age 58.9 ±11.9 (34～88)years, were randomly divided into transradial artery access for primary PCI (TRA pPCI) group of 106 cases and transfemoral artery access for PCI (TFA pPCI) group of 102 cases during Sept, 2000 to Aug, 2002. The protocols of the manipulation duration and the effect for TRA pPCI and TFA pPCI procedures were respectively compared, including the time of transradial artery puncture and the rate of puncture success at first time ; the time of guiding catheter engaging into target coronary ostium; the rate of patence in infarct related artery (IRA); total duration of manipulation and the successful rate.The incidence of complications such as bleeding, vessel injury,thrombi and embolism as well as the average stay of hospitalization between two groups was compared. The status and the incidance of vessel spasm were observed and the effect of medicine administration to prevent from and relieve the vascular spasm was evaluated. The time of Allen’s test before and after TRA pPCI , the inner diameter and the peak of blood velocity of the right and left radial artery were investigated with color Doppler vessel echography as well as the complications of radial artery were followed up 1 month after TRA pPCI procedure. Results Two cases in every TRA pPCI and TFA pPCI groups were crossed over each other because procedure of the transradial or transfemoral access was failure. One handred and six vessels (48 vessels in LAD,22 vessels in LCX and 36 vessels in RCA) associated with 28 vessels of total occlusion in TRA pPCI group and 102 vessels (51 vessels in LAD,18 veesles in LCX and 33 vessels in RCA) with 24 vessels in total occlusion in TFA pPCI group were angioplasticized . The successful rates of the first time puncture in access artery, the re patence IRA and pPCI were similar in TRA pPCI and TFA pPCI groups ( 93.4% vs 96.1% ;100% vs 100%; 96.2% vs 97.1% , P >0.05 ). There were no significant diffierence in the average time of puncture time of access artery ,engaging in target vessels of guiding catheters and the total procedure of PCI between the two groups ( 1.3 ±0.3s vs 1.2 ±0.3s ; 6.0 ±1.6min vs 5.8 ±0.9min ; 49.2 ±24.1min vs 46.5 ± 26.4min , P >0.05 ). The access artery complications such as bleeding ,hematoma and embolism as well the veneous thrombosis in TFA pPCI group were much more than those in TRA pPCI group(p< 0.01 ). Although slight artery spasm of 4.7% cases in TRA pPCI group was happened during the procedure of PCI , the procedure had being continued after administration of medicine to release the spasm. The time of Allen’s test ,diameter and the systolic velocity of blood in daul radial arteries were no significant change before and after pPCI.Conclusions The duration and effect by TRA pPCI for AMI with stable hemodynamics was similar to TFA pPCI. The complications such as of bleeding,vessel injury, thrombi and embolism by TRA pPCI were few, and it was unnecessary to discontinue the anticoagulation medicine. TRA pPCI might be selected as a access vessel for pPCI in AMI patients with stable hemodynamics.

Outcomes of percutaneous coronary intervention in patients ≥ 75 years： one-center study in a Chinese patient group

Objective To investigate the clinical and perioperative characteristics of patients ≥ 75 who undergoing percutaneous coronary intervention （PCI） and to evaluate the risk factors related to short-term post-PCI mortality in this specific patients group. Methods 1,035 consecutive subjects who underwent PCI from December 2011 to November 2013 were divided into four categories： （1） patients with stable angina （SA） 〉 75 years （n = 58）; （2） patients with SA 〈 75 years （n = 218）; （3） patients with acute coronary syndrome （ACS） ≥ 75 years （n = 155）; （4） patients with ACS 〈 75 years （n - 604）. A multivariable logistic regression analysis was conducted to detect risk factors of six-month mortality in patients ≥ 75 years who had undergone PCI. Clinical comorbidities, in-hospital biochemical indicators, perioperative data, in-hospital and six-month outcomes were analyzed and compared among the four groups. Results Compared with the younger group, pa- tients 〉 75 years were more likely to have hypertension, history of stroke, chronic obstructive pulmonary disease, peripheral vascular disease, cardiogenic shock and malignant mxhythmia, and they were admitted to hospital with relative lower weight, hemoglobin, albumin, triglyceride, higher creatinine, uric acid, urea nitrogen and pro-BNP. Left main artery lesions, multi-vessel, calcified lesions, chronic totally occlusion were also more likely to be seen in the elderly group. Univariate analysis revealed that age 〉 85 years, cardiogenic shock or severe arrhythmia at ad- mission, emergency PCI, prior stroke and chronic kidney disease were related to six-month mortality in elderly patients 〉 75 years who underwent PCI. Multivariable logistic regression showed that cardiogenic shock or severe arrhythmia at admission, chronic kidney disease and prior stroke were independent risk factors predicting six-month mortality in elderly patients 〉 75 years who had undergone PCI. Conclusions Our data showed that, compared with patients under 75 years, elderly patients （〉 75 years） who had undergone PCI had a relative higher risk of mortality, and more often accompanied with multi-comorbidities, severer admission conditions and complex coronary lesions. Better evaluation of risk factors and more intensively care should be taken to patients 〉 75 years who had undergone PCI therapy to reduce complications.

Percutaneous coronary interventions in the elderly:a 10-year experience in Northern New England

Background There is a paucity of information available for clinical decision making applying to the elderly patient population. Therefore, data of percutaneous coronary interventions (PCI) including demographic information on the elderly patients, procedural practices, and outcomes are needed. Objectives and Methods From consecutive PCIs of participating institutions, demographics data, clinical, angiographic success and adverse clinical outcomes were collected. Standard statistical methods were used to compare crude differences in patient and procedural characteristics across age groups. Results At baseline, the prevalence of comorbid conditions ( renal failure and heart failure) increased with age. Unstable angina or a non-ST elevation MI were the most common indications for PCI across all age groups. Fewer patients ≥ 80 years old were undergoing primary PCI and older patients were somewhat less likely to receive a Ⅱb/Ⅲa receptor blocker. Slightly more patients ≥ 80 years old underwent a 2-vessel PCI ( consistent with them having more multivessel disease) and these patients were more likely to have an intervention on a Type C lesion. Compared to patients ＜ 50 years old, those aged ≥ 70 years old had a significantly increased risk of death, MI, stroke, or vascular complications at the access site. Conclusions This study suggests increasing age is associated with increasing risk for an adverse outcome following PCI. This is in part attributable to case-mix but likely, also related to the changing physiology of aging. Despite the increased risk of the procedure, the clinical success rate for PCI is quite high and makes it a reasonable alternative for the treatment of CAD in the elderly.

Angiographic and clinical outcomes in elderly subjects treated with percutaneous coronary intervention following fibrinolytic administration for ST-elevation myocardial infarction

Background Prior studies have demonstrated that the achievement of faster coronary artery flow following reperfusion therapies is associated with improved outcomes among ST-elevation myocardial infarction (STEMI) patients. The association of patient age with angiographic characteristics of flow and perfusion after rescue/adjunctive percutaneous coronary intervention (PCI) following the administration of fibrinolytic therapy has not been previously investigated. Objectives and Methods We examined the association between age (≥ 70 years or ＜ 70years)and clinical and angiographic outcomes in 1472 STEMI patients who underwent rescue/adjunctive PCI following fibrinolytic therapy in 7 TIMI trials. We hypothesized that elderly patients would have slower post-PCI epicardial flow and worsened outcomes compared to younger patients. Results The 218 patients aged ≥ 70 years (14.8%) had more comorbidities than younger patients. Although these patients had significant angiographic improvement in TIMI frame counts and rates of TIMI Grade 3 flow following rescue/adjunctive PCI, elderly patients had higher (slower)post-PCI TIMI frame counts compared to the younger cohort (25 vs 22 frames, P = 0.039), and less often achieved post-PCI TIMI Grade 3 flow (80.1 vs 86.4%, P = 0.017). The association between age ( ≥70 years) and slower post-PCI flow was independent of gender, time to treatment, left anterior descending (LAD) lesion location, and pulse and blood pressure on admission. Elderly patients also had 4-fold higher mortality at 30 days (12.0 vs 2.7%,P = 0. 001 ). Conclusions This study suggests one possible mechanism underlying worsened outcomes among elderly STEMI patients insofar as advanced chronological age was associated with higher TIMI frame counts and less frequent TIMI Grade 3 flow after rescue/adjunctive PCI.

Safety and feasibility of transradial coronary intervention in Chinese elderly patients

Objective To assess the feasibility and safety of transradial approach in Chinese elderly patients undergoing coronary intervention.Methods In this prospective study,764 elderly patients with coronary artery disease received percutaneous coronary intervention via either a transradial approach(TRA group)or a transfemoral approach(TFA group).The procedural success rate,success rate of artery access,puncture time,fluoroscopy time,dose of contrast,local complications and post-procedural pulmonary embolism were recorded and compared between 2 groups.Results There was no significant difference of the procedural success rate between the TRA group and the TRF group(96.3%vs.98.2%,P>0.05);there were also no differences of success rate of cannulation,mean fluoroscopy time and mean dose of contrast between the 2 groups.The mean puncture time was longer in the TRA group than in the TFA group(3.8±2.1 min vs.2.0±3.4 min,P<0.05).However,there were fewer access site-related complications in the TRA group than in the TFA group.Post-procedural pulmonary embolism occurred in 2 patients in the TFA group but none in the TRA group.Conclusion Transradial coronary intervention was feasible and safe in most Chinese elderly patients when performed by experienced operators.

Percutaneous coronary intervention in the elderly:a growing need for a growing population

Persons aged 80 and above are the fastest growing age group in the United States population, having increased 50% since 1990 and predicted to grow another 25% by 2020.

The Benefits of Patients’ Information regarding Dietary Habits before Percutaneous Coronary Intervention: A 3- and 6-Month Follow-Up

Aim: To evaluate the benefits of counseling intervention related to dietary habits changes on patients following percutaneous coronary intervention (PCI). Materials and Methods: A randomized counseling intervention study, with a 3- and 6-month follow-up was performed on 230 patients who underwent PCI. They were randomly allocated to the intervention (n = 93) or the control group (n = 137). A 3- and 6-month telephone follow-up was performed for dietary habits evaluation. Data analysis was performed by using the statistical package SPSS, ver. 20.?Results: Compared with control group, intervention group had higher prevalence of hypertension, history of diabetes and dyslipidemias and history of acute myocardial infraction, with no statistical difference. Moreover, patients in control group were more likely to be ex-smokers (p = 0.01). Post hoc tests using the Bonferroni correction revealed that mean TCHOL concentration while patients admitted to hospital differed statistically significantly between the time points of 3 and 6 months (209 ± 67 mg/dl vs 174 ± 34 mg/dl vs 176 ± 36 mg/dl), p= 0.005 and p = 0.042 respectively. However, there was no statistical significant difference between 3 months and 6 months measurements. Mean glucose concentration while patients admitted to hospital differed statistically significantly between the time points of 3 and 6 months (108 ± 40 mg/dl vs 95 ± 21 mg/dl vs 95 ± 23 mg/dl), p =0.009 and p = 0.012 respectively. However, there was no significant statistical difference between 3 months and 6 months measurements, (p = 1.000). Conclusion: A nurse-led program regarding dietary habits modifications on patients undergoing PCI should be performed along with a long-term follow up after hospital discharge.

Feasibility of percutaneous coronary intervention via transulnar artery approachin selective patients with coronary heart disease

Objective To probe the clinic feasibility of percutaneous coronary intervention(PCI) via transulnar artery approach (PCI TRU).Methods Fourty patients with unstable ischemic manifestation(male 34,female 6;age 59.3 ±9.10 years)whose radial artery of right hand was thin with a weak pulse that was not suitable to transradial artery PCI while whose ulnar artery was thick with a strong pulse based on their larger diameter in ulnar artery as compared with those in radial artery ( 3.30 ±0.22mm vs 2.43 ±0.33 mm, P <0.05 ) by the investigation of vessel echography,but revesered Allen’s test for radial and ulnar artery was positive,were selected as the subjects for PCI TRU. The radio of ulnar artery versus radial artery was 1.35:1.00 and the time of Allen’s test in ulnar artery side was shorter than that in radial artery side ( 2.70 ±0.36 s vs 4.68 ±0.52s , P <0.05 ) before PCI. The efficiency of PCI TRU was evaluated. The time of manipulative duration for each procedure of PCI TRU was recorded. The time of Allen’s test, luminal diameter (mm) , cross area of vessel lumin (mm 2), blood velocity (Vs max), blood resistance (RI) in ulnar artery and radial artery and the level of blood oxygen in finger (PaO 2、SatO 2) were measured and recorded , respectively , as well were compared quantitatively before and after 1 month of procedure . Results Fourty eight lesion segments of 42 vessels in all patients were angioplasticized successfully via TRU by 6F guiding catheter including 23 segments of type B1 , 14 segments of type B2 and 11 segments of type C. PCI TRU in all of 40 patients was performed successfully. Fourty eight stents were implanted including 2 lesions of intrastent restenosis angioplasticized with cutting balloon technique before re stenting . The average time of manipulative duration of guiding catheters engaging in osicum of target coronary, crossing the vessel lesions of guidewire, dilatation and implantation of stents,and under X ray fluoroscopy were 4.30 ±0.59 min , 2.52 ±0.40min , 2.66 ±0.40 min ,and 25.9 ±0.49 min , respectively, and the total time of the whole procedure was 56.6 ±14.8 min . When the ulnar introducer was taken off, the access site in ulnar artery was suppressed by tourniquet with no bleeding in the access site and no limitation of physical activation under maintaining infusion of heparin immediately after procedure . There was no significant change in the diameter of ulnar artery and the time of Allen’s test after 1 month of PCI procedure as compared with those before procedure ( 3.22 ±0.48mm vs 3.26 ±0.22 mm , P >0.05 ; 2.96 ±0.98 s vs 2.72 ±0.47 s , P >0.05 ). No significant change was found in the parameters of blood velocity , cross area of vessel lumin, blood resistance and the level of blood oxygen in finger after 1 month of PCI procedure. The average total hospital stay was 5.21 ±0.43 days. Following up 1 month, no complications such as occlusion of ulnar artery, abnormal sensitivity and movement disability were found in right hands in all patients.Conclusions The ulnar artery might be selected as one approach of antebrachial artery for PCI in the patients with coronary heart disease whose radial artery was difficulty as access vessels of PCI, while reversed Allen’s test for radial and ulnar artery are positive and the luminal diameter of ulnar artery was larger than that of radial artery.

Outcomes after percutaneous coronary interventions in patients with chronic kidney disease

Introduction Chronic kidney disease (CKD) is a significant contributor to cardiovascular morbidity and mortality.Patients with CKD are known to have a greater prevalence of cardiovascular disease than the general population,1 and patients with concurrent CKD and coronary artery disease (CAD) have greater mortality than patients without CKD.2-4 The rate of cardiovascular mortality is approximately 50%,five to 10 times higher than the general population.

Invasive strategy in elderly patients with acute coronary syndrome in 2018: close to the truth?

Elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes(ACS).The optimal management of ACS in these patients is still a challenge due to their clinical peculiarities and the paucity of specific data,and they have been traditionally managed more conservatively mainly based on subjective criteria.In ST^segment elevation acute myocardial infarction urgent reperfusion is the standard of care and there is no upper age limit.In non-ST segment elevation acute myocardial infarction evidence is controversial,incomplete and mainly focused on chronological age.While a strict conservative strategy should be avoided,routine invasive strategy may reduce the occurrence of myocardial infarction and need for revascularization at follow-up with no established benefit in terms of mortality.Clinical characteristics associated with aging,such as comorbidities and frailty,further discriminate patient's risk beyond age.Evidence is scarce,but it suggests that these features may modulate the benefit of invasive strategy in this population.Ongoing trials should clarify the optimal management of ACS based on these parameters.

Age-dependent impact of the SYNTAX-score on longer-term mortality after percutaneous coronary intervention in an all-comer population

Background The Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery （SYNTAX）-score is a validated tool for risk stratification and revascularization strategy selection in patients with complex coronary artery disease. The aim of this study was to analyse its age-related prognostic value. Methods SYNTAX-score was calculated in 1331 all-comer patients undergoing percutaneous coronary intervention （PCI）： 463 patients ≥ 75 years and 868 patients 〈 75 years. Outcomes of interest were all-cause mortality at one and two years. Results A significant interaction of age and SYNTAX-score for mortality was observed at two-year （Pinteraction= 0.019） but not at one-year follow-up （Pinteraction= 0.594）. In multivariable analysis, SYNTAX-score independently predicted 1-year mortality in both age groups （〈 75 years, hazard ratio （HR）： 1.43, 95% confidence intervals （CI）： 1.03-2.00, P = 0.034; and 〉 75 years, HR： 1.37, 95% CI： 1.01-1.85, P = 0.042）, but only two-year mortality among younger patients （〈 75 years, HR： 1.33, 95% CI： 1.01-1.76, P = 0.041; and ≥ 75 years, HR： 1.11, 95% CI： 0.87-1.41, P = 0.394）. SYNTAX-score tertiles were useful to stratify 1-year mortality in both, patients 〈 75 years （SYNTAX-score 〈 9, 3.8%; 9-20, 5.3%; 〉 20, 10.3%; P = 0.004） and 〉 75 years （SYNTAX-score 〈 11, 5.7%; 11-22.5, 16.1%; 〉 22.5, 18.7%; P = 0.003）, but two-year mortality only among patients 〈 75 years （SYNTAX-score 〈 9, 6.5%; 9-20, 7.6%; ≥ 20, 15%; P 〈 0.001） and not among ≥ 75 years old patients （SYNTAX-score 〈 11, 19.4%; 11-22.5, 26.3%; _〉 22.5, 27.9%; P = 0.138）. Conclusions Age modi- fies the impact of the SYNTAX-score on longer-term mortality after PCI. Among patients 〈 75 years, the SYNTAX-score independently predicts the risk of death at one and two years after PCI, while among patients 〉 75 years its predictive role is limited to the first year after PCI. Further studies are needed to evaluate the value of SYNTAX-score for selecting the most appropriate revascularization strategy among elderly patients.

Evaluation of coronary plaque and stent deployment by intravascular optical coherence tomography in elderly patients with unstable angina and non-ST-elevation myocardial infarction

Objective To evaluate the feasibility and efficacy of intravascular optical coherence tomography(OCT)in the assessment of plaque characteristics and drug eluting stent deployment quality in the elderly patients with unstable angina(UA)and non-ST segment elevation myocardial infarction(NSTEMI).Methods OCT was used in elderly patients undergoing percutaneous coronary interventions.Fifteen patients,9 males and 6 females with mean age of 72.6±5.3 years(range 67-92 years)were enrolled in the study.Images were obtained before initial balloon dilatation and following stent deployment.The plaque characteristics before dilation,vessel dissection,tissue prolapse,stent apposition and strut distribution after stent implantation were evaluated.Results Fifteen lesions were selected from 32 angiographic lesions as study lesions for OCT imaging after diagnostic coronary angiography.There were 7 lesions in the left anterior descending artery,5 lesions in the right coronary artery and 3 lesions in the left circumflex coronary artery.Among them,12(80.0%)were lipid-rich plaques,and 10(66.7%)were vulnerable plaques with fibrous cap thickness 54.2±7.3μm.Seven ruptured culprit plaques(46.7%)were found;4 in UA patients and 3 in NSTEMI patients.Tissue prolapse was observed in 11 lesions(73.3%).Irregular stent strut distribution was detected in 8 lesions(53.3%).Vessel dissections were found in 5 lesions(33.3%).Incomplete stent apposition was observed in 3 stents(20%)with mean spacing between the struts and the vessel wall 172±96 mm(range 117-436 mm).Conclusions 1)It is safe and feasible to perform intravascular OCT to differentiate vulnerable coronary plaque and monitor stent deployment in elderly patients with UA and USTEMI.2)Coronary plaques in elderly patients with UA and USTEMI could be divided into acute ruptured plaque,vulnerable plaque,lipid-rich plaque,and stable plaque.3)Minor or critical plaque rupture is one of the mechanisms of UA in elderly patients.4)Present drug eluting stent implantation is complicated with multiple tissue prolapses which are associated with irregular strut distributions.5)The action and significance of tissue prolapse on acute vessel flow and in-stent thrombus and restenosis need to be further studied.

Changes in the safety paradigm with percutaneous coronary interventions in the modern era:Lessons learned from the ASCERT registry

In the past,comparative effectiveness trials evaluating percutaneous coronary interventions(PCI),using either balloon angioplasty or bare metal stent(BMS) implantation,versus coronary artery bypass surgery(CABG) found similar survival rates at long-term follow-up with both revascularization strategies.Two major meta-analyses of these trials reported 5-and 6-year comparative effectiveness between PCI and CABG:one included only four trials that compared PCI with BMS implantation versus CABG whereas the largest one also included trials using balloon angioplasty.In these studies,the authors observed no survival differences between groups although a significant survival advantage was seen in diabetics treated with CABG and this benefit was also perceived in elderly patients.In both reports,number of involved vessels,presence of left anterior descending artery stenosis or poor left ventricular ejection fraction were no predictors of poor survival with PCI.Therefore,extent of the coronary artery disease(CAD) was not associated with poor outcome after PCI in the pre-drug eluting stent(DES) era.Recently,the ASCERT(Database Collaboration on the Comparative Effectiveness of Revascularization Strategies) registry found higher mortality rate with PCI in patients ≥ 65 years old in comparison with CABG,and advantages of surgery were seen in all subgroups including those at low risk.In this registry,PCI was accomplished by implantation of the first type of DES designs in 78% of cases.The intriguing observation of high mortality rate with PCI,including for non-diabetics and patients with two-vessel CAD,meaning a lack of clinical benefit with DES implantation,had not been seen previously.The study was not randomized,although its results are largely strengthened by its sample size.In this manuscript,the authors describe other registries and randomized trials reporting similar results supporting the findings of the aforementioned study and explore the reasons for these results,while also searching for potential solutions.