Page 109 - Read Online

Page 6 of 17 Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29

Table 1. Comparison of the predictive value of the CHA2DS2VASc score for stroke and atrial fibrillation in elderly patients
based on gender
Elderly > Baseline score Score after adding Target high risk Stroke risk (%) at Stroke risk (%) Maximum
75 years old according to age a single additional score for atrial baseline score after adding a possible score
and gender only risk factor fibrillation single additional
risk factor
Male 2.0 3.0-4.0 ≥ 3.0 2.2 3.2-4.0 8.0
Female 3.0 4.0-5.0 ≥ 3.0 3.2 4.0-6.7 9.0

Aside from this, the CHA2DS2VASc score is a recognized predictor of the risk of having cerebrovascular
[45]
episodes. Patients aged 75 or more are assigned 2 on the scale, making the elderly patients more likely to
end up with higher scores. Adding the factor of gender, elderly females have a risk of 3 at baseline without
adding the risk attributed to the other comorbidities on the scale and the PCI procedure. Interestingly,
CHA2DS2VASc score of 2 or more was also found to be predictive of atrial fibrillation after cardiac
procedures . Table 1 summarizes the significance of CHA2DS2VASc score in predicting stroke and atrial
[46]
fibrillation in the elderly population.

PCI TEMPORAL TRENDS
Historically, there have been a lot of variations in the reported data regarding procedure outcomes and
mortality rates among the older population undergoing PCI. Some of the papers published in the late eighties
through nineties showed the success rate of percutaneous transluminal coronary angioplasty (PTCA) in the
elderly to be approximately 82%-84% and highly variable mortality rates [47-49] , however, Both success and
mortality rates have varied a lot in other papers published in the same era. Kern et al. reported in 1988
[50]
a clinical success rate of a 67% in a group of 21 patients who had undergone PTCA in their octogenarian
years. After that, a clinical success rate of 57% was reported in 43 patients aged 75 years and older by other
investigators . In contrary, Jeroudi et al. demonstrated PTCA angiographic and clinical success in 50
[51]
[52]
and 49 patients, respectively out of 54 octogenarian patients (93% and 91%, respectively). Procedure success
has differed considerably between septuagenarians, octogenarians and older participants in the same group
of old aged patients as it was 85%, 73%, and as low as 50% for patients aged 70 to 74, 75 to 79, and 80 years
and older . Also, procedural mortality rate varied and reached up to 19% during the same era [50,53] . Many
[49]
cardiac and non-cardiac complications were reported and occurred in more than third of the participants
in some of the previous studies [47,50] . Although PCI has been proven to be feasible in the older population,
the previous rates of success, procedural mortality, and consequent complications were unacceptable to
many healthcare providers which created a high level of prudence and caution before deciding to perform
PCI on such patients. Over years, several advanced technologies have been introduced, useful cardiac
imaging modalities have been more available, less invasive approaches and protocols have been investigated
to be adopted, and the operator techniques have been improved. As a result, a less conservative trend in
performing more invasive procedures on older patients has gradually appeared. In a cohort of 31,758 patients
who had undergone PCI between 2000 and 2007, the incidence of PCI in patients aged 75 and older has
increased from 56/100,000 in 2000 to 216/100,000 in 2007 . PCI share of older patients has increased even in
[54]
the very old segment such as the nonagenarians. Among 26,696 PCI performed over 11 years, only 177 were
performed on nonagenarians, however, the prevalence of PCI in this very subgroup of patients was 0.17% in
2004 and increased to 1.22% in 2014 . Recent studies have also shown some changes in PCI mortality and
[41]
complications trends. Generally, the success rate has improved, mortality and complications risk started to
approach those of younger population. In a very recent study that was published in 2018, the outcomes of
PCI in octogenarians and younger patients using second-generation cobalt-chromium everolimus-eluting
stents were practically the same . Angiographic success was 98.4% in octogenarians and 98% in younger
[42]
participants (P = 0.85). A lot of both in-hospital and 1-year follow-up post PCI-complications were also
comparable between the 2 groups. In-hospital major bleeding events and cerebrovascular accidents have not
occurred in either of the 2 groups, however, acute kidney injury occurred more frequently in octogenarians,