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Page 2 of 17 Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29

INTRODUCTION
Ischemic heart disease is one of the major challenges that encounter healthcare providers all over the world.
It is considered the leading cause of death with acute coronary syndrome (ACS) accounting for more than
30% of causes of mortality in the elderly population (aged 65 years or older) . The elderly group of population
[1]
has grown substantially. For many reasons, the rate of growth has increased exponentially and will become
more pronounced in the future, especially in the developed world. In 1970, the population aged 65 years and
older constituted only 9.8% of the total population in the United States, however, in 2012 it increased to 13.7%
and it is expected to exceed 20% by the year 2030. Octogenarians and older populations constituted a smaller
segment of only 3.7% comparing to their younger counterparts in 2012 but it is also expected to jump up to
3.9% and 5.4% by 2020 and 2030, respectively . Despite the recent advancements that have been achieved
[2]
in both clinical and interventional cardiology realms, the management of coronary artery disease (CAD) in
the elderly is still a major concern, both for cardiac interventionists and surgeons. Historically, older patients
often receive conservative management rather than invasive procedures and there is a paucity of clinical
trials investigating the challenges and outcomes of more invasive treatment strategies for that very segment
of the population. Therefore, this relative under-representation of elderly in clinical trials and the consequent
lack of knowledge made many cardiology interventionists more reluctant to perform percutaneous coronary
[3]
intervention (PCI) for very elderly patients which hinders their optimal evidence-based therapy . Recently,
safety and outcomes of PCI in the older population has started to receive more attention, therefore, changes
in its trends have to be studied thoroughly. In this review, we discuss age and its impact on older patients’
stratification and prognosis, the most relevant challenges that make PCI more difficult in this group of
patients, recent changes in trends of PCI in the elderly, and the latest guidelines and recommendations.

AGE AND PCI
There is no specific age beyond which PCI cannot be performed, however, with increasing age less
invasive therapy is usually preferred. In the literature, even a few centenarians underwent successful PCI
procedures . The oldest reported case was a 106-year-old lady who presented with inferior wall ST-segment
[4,5]
[5]
elevation acute myocardial infarction (STEMI) . It is also difficult to assign a clear-cut age threshold to
classify patients based on their ages as risky vs. non-risky patients. However, according to the data from the
Global Registry of Acute Coronary Events (GRACE), patients aged 75 years or more had more cardiovascular
risk factors such as history of congestive heart failure (CHF), myocardial infarction (MI), hypertension,
[3]
atrial fibrillation, diabetes mellitus, and stroke comparing to younger patients . Also, patients aged 75 years
and older were considered a special group in the American College of Cardiology Foundation/American
Heart Association (ACCF/AHA) guidelines . Thus, in this review, we define risky old patients as patients
[6,7]
aged 75 or more.

Age of patients presenting with ACS has a significant prognostic value and it is considered the second most
important predictor of mortality after Killip class as it has been shown that the in-hospital mortality risk of
a patient with ACS increases by 1.7 fold for each 10 years and by 2 folds for each Killip class deterioration .
[8]
Risk stratification plays a crucial and decisive rule during the initial management of ACS patients, as it
helps to determine the appropriate site of care and the intensity of therapy. Age among other patients’
demographic characteristics profoundly affects this stratification as well as the initial estimate of death and/
or other cardiac events even before performing any physical examination or reviewing electrocardiograms
[6]
(ECG) and laboratory results . This is why, age is usually a vital criterion in several scoring systems that are
used to estimate the in-hospital, 30 days, and even 1-year mortality rates of patients presenting with ACS
and risk of complications as well. Among these scoring systems, the GRACE risk score [9,10] , the thrombolysis
in myocardial infarction (TIMI) risk score [11,12] , and the “platelet IIb/IIIa in unstable angina: receptor
suppression using integrilin therapy” (PURSUIT) risk score . According to the GRACE score, age of more
[13]
than 75 adds a mortality risk score of 73. For TIMI score, age of more than 65 adds a 5% risk at 14 days of:
all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.