Despite Challenges, Coronary Revascularization Benefits the Elderly

The current rate at which the U.S. population is aging is remarkable. Increasing life span and the baby boomer generation will double the number of Americans aged 65 years and older in the next 25 years to upward of 72 million, according to a 2013 report from the CDC. Heart disease continues to be the leading cause of death in the U.S. population and, therefore, it is essential that we understand the trends in coronary artery revascularization in the elderly.

The Complicated Older Patient

The elderly population presents in a complex and challenging manner to the clinician. They present with atypical symptoms in the setting of multiple comorbidities. As the body ages, there is a reduction in lean body mass, relative increase in body fat, polypharmacy, decreased renal function and changes in gut motility, thus putting the elderly population at risk for significant side effects from standard medical therapy.

The inability to tolerate a wide spectrum of medications along with underrepresentation in prospective clinical trials further exposes the aging population to substandard levels of care.

Effects of Aging on Arteries

The natural process of aging results in intrinsic changes in the myocardium and cardiac vasculature. Over time, the coronary arteries become dilated, tortuous, and develop diffuse and localized calcifications, ultimately leading to impaired endothelial function. Increased arterial and aortic stiffness results in increased afterload, which over time increases myocardial thickness. Progression of myocardial remodeling leads to increased fibroelastic changes in the ventricles, thereby initially worsening diastolic ventricular function and increasing left ventricular end-diastolic pressure (LVEDP). Subjected to prolonged periods of increased LVEDP, the noncompliant left ventricle begins failing, resulting in decreasing ejection fraction and cardiac output.

If identified early, the ischemic cascade may be altered by appropriate noninvasive testing and possible intervention. However, significant bias in appropriately testing and, ultimately, intervening on the elderly exists, thereby exposing the population to a preventable progression of CAD.

PCI in the Elderly

A review of more than 1 million patients in the National Cardiovascular Data Registry (NCDR) from 2010-2011 demonstrated that of all patients who had a diagnostic angiogram and PCI, only 12% of the population was older than 80 years (Figure 1), whereas the incidence of CAD in men and women older than 85 years is 43% and 45%, respectively, with the incidence of acute MI being more than threefold in patients older than 75 years in 2007 vs. the younger population. The hesitation of operators about performing PCI on the elderly likely stems from studies demonstrating increased rates of CVD, renal failure, HF, bleeding and death in the elderly after PCI. However, the risk for adverse events in the elderly are mitigated by the clear benefit of invasive strategy in patients aged at least 65 years, demonstrating a RR reduction of 0.66 and overall reduction of 0.61 vs. conservative medical therapy in patients with ACS (Figure 2). PCI has also demonstrated benefit in 30-day event rates in patients older than 70 years vs. lytic therapy.

Source: Healio. CardiologyToday's Intervention
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