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Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29 Page 3 of 17

As far as the PURSUIT score, age of 70 or more adds a mortality only risk of 4 points and a risk of mortality
and infarction of 11 points.

PCI CHALLENGES IN OLDER POPULATION
Providing proper management and rehabilitation for older patients could be very challenging. Certainly,
this becomes more sophisticated if a more invasive procedure such as PCI is required. Factors that make
interventional cardiologists more resistant to perform PCI for an elderly patient can be either general factors
related to the patient’s general status such as frailty, co-morbidities, functionalities of their cardiovascular
and other systems or local factors related to coronary lesions such as the complexity of these lesions. Here,
we discuss the most relevant factors in more details.

FRAILTY AND MULTI-MORBIDITY
Frailty is often defined as gradual insufficiency and regress of multiple body systems that eventually lead to
an ultimate state of low reserve, functional/ cognitive decline, and inability to cope with different stressors.
It is also considered by geriatricians to be a clinical syndrome that makes patients vulnerable to a variety
of adverse outcomes . Frailty becomes more apparent with aging, and unfortunately, even with the best
[14]
healthcare and interventions provided to the elderly in order to support, improve, and maintain their quality
of life, frailty is usually inevitable at a certain point of their age . Based on the analysis of data from 4735
[15]
out of 5888 participants of the Cardiovascular Health Study (CHS), the mean ages of non-frail, intermediate
state, and frail patients were 71.5, 73.4, and 77.2 years, respectively. The same study demonstrated a higher
prevalence of cardiac risk factors such as CHF, history of angina, MI, peripheral vascular disease (PVD), and
carotid stenosis in frail patients . Some inflammatory markers such as C-reactive protein (CRP) and some
[16]
clotting factors like factor VIII and fibrinogen were found to be in higher levels in frail patients compared
to non-frail ones, suggesting that the high prevalence of some PCI adverse outcomes such as thrombotic
complications in the aging frail population can be explained by an inflammatory process yet to be
understood . With aging, a variety of cardiac and non-cardiac morbidities usually exist concurrently with
[17]
the patients’ coronary problems which makes it even more difficult for them to suit such procedures and to
overcome any ominous adverse event. In the United States, the prevalence of cardiac diseases, hypertension,
stroke, chronic obstructive pulmonary disease (COPD), kidney diseases, arthritis, and a lot of cancers is
higher among the population aged 75 and older more than any other age group .
[18]

POLYPHARMACY
With the increased prevalence of different morbidities among older patients, being on multiple medications
at the same time is an expected consequence. Polypharmacy is more pronounced in the geriatric population
and it makes patients more prone to many cardiac events which makes deciding PCI for them more unlikely.
Data collected from 384 old frail patients participated in the Geriatric Evaluation and Management (GEM)
Drug Study revealed that more than 40% of the participants were on 5 to 8 different medications and more
than 37% had even more than 8 medications at the time of their discharge . In a prospective cohort study
[19]
on old aged men with a mean age of 77 years, polypharmacy was associated with poor cardiovascular events
such as MI and stroke with a statistically significant hazard ratio of 1.09 (95% CI: 1.06-1.12) . In addition
[20]
to that, many factors associated with advanced age such as the decrease in renal function, low glomerular
filtration rate, decreased liver mass and blood flow can alter many drugs pharmacokinetics and reduce their
hepatic and renal elimination predisposing patients to more adverse events . Another challenge that could
[21]
be faced during dealing with any elderly who needs PCI, is adjusting the dose of their cardiac medications
as changes in water-fat balance in their body composite affect drugs distribution and dosing to a significant
extent. Older patients have a lower total body water that leads to a lower volume of distribution and a
higher serum level of water soluble medications such as digoxin that necessitate reduction of its loading