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Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29 Page 9 of 17

TIME OF INTERVENTION
There are some conflicting data regarding the perfect timing of PCI in patients presenting with STEMI,
however, several previous studies have shown that shorter door-to-balloon time (DTBT) is associated
with better outcomes and many investigators believe that attempts to avoid any DTBT delay should be
adopted regardless the patient’s baseline risks [80,81] . Optimally, reperfusion should be attained within the
recommended 90-minute window, however, many patients still undergo PCI beyond this time limit .
[82]
DTBT has been shown to be longer among older populations compared to their younger counterparts in
several recent studies [57,62,79] . The median DTBT in a cohort of 2972 consecutive patients who underwent
primary PCI for STEMI was 70, 76, and 80 min for patients aged < 75, 75 to 84, and ≥ 85 years, respectively
(P < 0.001) . Being an old age patient per se, has been shown to be an independent predictor for the door-
[57]
to-balloon delay . Other predictors have been described such as non-daytime presentation, the absence
[83]
of typical chest pain, the need for hospital transfer, female sex, and non-white race . Elderly patients with
[83]
ACS often present with non-specific and atypical symptoms like nausea, vomiting, diaphoresis, and dyspnea.
Chest pain occurs only in approximately 40% of patients older than 85 years . Also, the higher prevalence
[84]
of left bundle branch block (LBBB) in older population patients makes the electrocardiographic diagnosis of
STEMI more difficult . These unusual presentations of ACS and time-wasting factors may cause some sort
[84]
of delayed diagnosis and management which consequently leads to worse outcomes in elderly undergoing
PCI that must be investigated thoroughly in the near future.

AUXILIARY CARDIAC IMAGING UTILIZATION
Over the last years, we have witnessed dramatic advancements in the field of cardiac imaging. Several
imaging modalities such as transesophageal echocardiography (TEE), cardiac computed tomography (CT),
cardiac magnetic resonance imaging (CMR), and intravascular ultrasonography (IVUS) have been evolving
and their usefulness in the diagnosis and assessment of a variety of clinical and/or surgical situations has
been studied [85,86] . We believe that the optimal utilization of several cardiac imaging modalities can provide
an additive benefit to the patients undergoing PCI, especially among older populations. Moreover, the
integration of clinical and imaging data can assess patients’ prognosis and predict their clinical outcomes.
It also can define and classify several procedural complications and guide healthcare providers to decide
whether to adopt a conservative management strategy or to proceed with more aggressive options . For
[87]
instance, intra-operative TEE has been used to guide several procedures in the catheterization theater and
it provided useful assessments to some age-related PCI complications such as iatrogenic aortic intramural
hematomas and helped to assess the patient’s outcome and to decide the best management . Furthermore,
[87]
with the latest developments of three-dimensional TEE, more accurate intra-operative images of stent
scaffolds can be obtained which enabled some investigators to more confidently diagnose and assess some
PCI complications like LMCA stent protrusion and migration [88,89] . Thus, and as we mentioned above, with
the older populations usually having more frequent LMCA lesions than younger patients, they can benefit
from this modality. Also, IVUS and optical coherent tomography (OCT) have been shown to be useful in
the qualitative assessment and preparation of LMCA lesions and in stent sizing and optimization as well [90,91] .
In addition to that, post-PCI risk stratification has been proven to be helpful in evaluating STEMI patients’
prognosis. The use of CMR during the hyperacute phase of STEMI after primary PCI has been shown to be
safe and feasible . Although the value of most of these imaging modalities in the elderly undergoing PCI as
[92]
a separate high-risk group has not been investigated in large scales studies, many of them may provide useful
contributions during the management of these patients in the future.

DIFFERENT INDICATIONS OF PCI IN ELDERLY
It has been shown that PCI was indicated for older population in a wide spectrum of different clinical
situations with variable disease severities, from primary PCI in unstable old patients with STEMI and urgent
PCI for those presenting with non-STEMI and unstable angina pectoris to elective PCI for old patients with
stable CAD. Many previous studies have demonstrated that older patients who underwent PCI for unstable