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Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29 Page 5 of 17

vessels compared to only 24% of younger patients (P = 0.0001). Also, 22% of older patients vs. 38% of their
younger counterpart had only 1 diseased vessel (P = 0.0001) . The Synergy between Percutaneous Coronary
[24]
Intervention with TAXUS and Cardiac Surgery (SYNTAX) score has been used to predict clinical outcomes
in patients undergoing PCI especially those with LMCA lesions and/or multivessel coronary disease based
on their lesions complexity . More recently, this scoring system has been integrated with some independent
[32]
clinical variables such as the patient’s age, creatinine serum level, and left ventricular ejection fraction
(LVEF) to obtain the clinical SYNTAX score (CSS) . Both scoring systems have been shown to be valid
[33]
in risk stratification and early mortality prediction among older patients with ACS undergoing PCI. While
the SYNTAX score did not predict long-term clinical outcomes, the CSS was useful in predicting the 1-year
major adverse cardiac and cerebrovascular events, reflecting the potentially significant impact of the patient’s
clinical and demographic factors such as their ages on their clinical outcomes . Previous studies have also
[34]
shown that age is significantly associated with increased coronary artery calcium score [35,36] . Calcification of
the coronary system is associated with coronary artery disease (CAD) and coronary artery calcium content
is highly associated with increased cardiovascular events .
[36]

PCI ADVERSE EVENTS
As a result of the previously mentioned factors, PCI outcome is expected to be worse in the older patients
comparing to the general population. Indeed, the most devastating outcome would be death. Although
studies have demonstrated reasonable short and long-term PCI outcomes in the elderly, the in-hospital,
30 days, and even 1 to 5 years follow-up all-cause mortality rates are still higher [37-39] . Aside from death,
there is a higher chance that older frail patients experience a variety of complications that can occur
consequently as a result of this procedure and affect patients’ clinical outcome and quality of life than other
younger patients . Many cardiac complications have been described such as cardiogenic shock, acute MI,
[40]
acute ventricular septal rupture (VSR), iatrogenic coronary dissection, coronary perforation, and stent
thrombosis. Other non-cardiac complications have also been reported such as hemorrhage, acute kidney
injury, stroke, and access site complications like femoral or radial dissection and/or hematoma [41,42] . Major
bleeding is one of the complications associated with unfavorable clinical outcome. Pooled data from 5
different trials that participated in the RESOLUTE study program and included 5130 patients undergoing
PCI with the resolute zotarolimus-eluting stent showed that rates of some complications such as MI and
repeat revascularization in 1675 patients aged 70 years or older (33%) were similar to those of younger
participants, however, significant bleeding events occurred more frequently among older population.
In-hospital and 1-month follow-up bleeding complications occurred in 1.3% and 1.6% of patients aged
70 years or older, and 0.3% and 0.5% of younger participants (P = 0.009 and 0.014), respectively. Death
occurred in 26% of old patients who experienced bleeding events with a median time of 21 days between
the bleeding event and time of death . Another study showed an increase of 2.4% in over-all rates of
[38]
bleeding events among patients undergoing PCI in their octogenarian years than younger patients . Many
[37]
different bleeding complications have been reported to be associated with PCI such as, access site bleeding,
pericardial bleeding that can lead to tamponade, retroperitoneal bleeding, and gastrointestinal bleeding
as well . Beside age of the patient, many other variables have been proven to be an independent predictor
[37]
of unfavorable outcome in the elderly undergoing PCI. Reduced cardiac function with left ventricular
ejection fraction (LVEF) lower than 40%, Killip class of 3 or worse, cardiogenic shock, and hypotension
with systolic blood pressure (SBP) lower than 100 mmHg have all been identified as independent predictors
of an increased risk of 1-year mortality . Also, the activity of daily living (ADL) of old age patients after
[43]
PCI can be used to predict mortality. ADL assessment by Barthel index (BI) at the time of admission
and discharge has been investigated by Higuchi et al. to predict 1-year mortality in very old patients
[44]
undergoing PCI for ACS. They have shown that lower BI at the discharge of the patient can be a predictor
of higher mortality in patients aged 85 years and older with each 5 unites decrease in BI being associated
with 1.1 fold increase in 1-year mortality risk.