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Page 10 of 17 Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29

ACS constituted the bigger portion of the total elderly underwent PCI. Among 102 CAD patients aged 85 years
and older, PCI was indicated in an ACS setting in 72.6% of them and only 24.5% of PCIs were performed
for patients with stable angina . In another cohort, 93% of 177 PCI performed on nonagenarians were
[93]
indicated in ACS settings and only 7% were elective PCI . It is worth mentioning that clinical presentation
[41]
and PCI indication are considered significant determinants of post-PCI clinical outcomes. As it has been
shown that short and long-term clinical outcomes are usually superior in older patients who underwent PCI
for stable CAD compared to unstable patients of the same age [93,94] . Among 102 PCI performed for a variety
of indications in very old patients, aged ≥ 85 years, there were 4 in-hospital deaths, all of them were patients
presented to PCI due to acute STEMI. However, there were no deaths among very old patients from the same
age group in whom PCI was indicated for stable coronary syndromes, post-STEMI, and other indications .
[93]
Teplitsky et al. reported a zero percent cumulative mortality rate at 6-month after elective PCI performed
[95]
for nonagenarian patients with stable CAD. The 6-month cumulative mortality rate in patients underwent
emergent PCI for clinically unstable ACS was 23% in the same study.

PCI AMONG OTHER REVASCULARIZATION AND REPERFUSION STRATEGIES IN ELDERLY
Generally, PCI is the most commonly used reperfusion strategy among all age groups . In terms of
[96]
revascularization in older patients with CAD, a variety of strategies have been utilized, from conservative
management with no revascularization at all to the most invasive surgical revascularization. However, the
decision to choose the best reperfusion strategy for this high-risk group of patients has never been simple.
Peiyuan et al. have compared the clinical outcomes of 3 groups of 3082 STEMI patients aged 75 years and
[97]
older. Reperfusion by PCI was performed in 1000 patients, fibrinolysis was administrated to 160 patients, and
the third group of 1922 patients did not have reperfusion therapy. PCI group had a significant lower mortality
rates than fibrinolysis and no reperfusion groups of 7.7%, 15%, and 19.9%, respectively, P < 0.001. Several
adverse outcomes such as recurrent MI and MI-related complications like heart failure and cardiac arrest
occurred less frequently in PCI group. Other previous studies from different populations have demonstrated
better clinical outcomes in patients underwent PCI compared to those whom received fibrinolysis in all
age groups including the elderly [98,99] . A meta-analysis of 22 randomized trials that included 6763 patients,
also showed higher death and adverse outcomes rates of patients whom received fibrinolysis compared
to primary PCI group among all ages except patients aged 50 years and younger . Another strategy that
[99]
involves combining fibrinolysis to urgent PCI can be potentially beneficial for elderly patients with ACS. The
pre-hospital administration of a reduced-dose fibrinolytic agent before urgent PCI, termed FAST-PCI, showed
better 30-day mortality rates than primary PCI alone, 4.2% vs. 18.1%, respectively, P < 0.01 in STEMI patients
aged 75 years and older without an increase in rates of major bleeding events, stroke, or reinfarction .
[100]
Despite that many health care providers are still hesitant to direct old patients toward PCI, it has been shown
that with aging, the frequency of PCI increases and that of coronary artery bypass grafting (CABG) decreases.
Nicolini et al. compared the clinical outcomes and adverse events between PCI and CABG in a cohort of
[101]
patients aged 80 years and older with multivessel disease or LMCA lesions. PCI was performed in 947 patients,
while 441 underwent CABG. It is worth mentioning that, all nonagenarian patients included in the PCI group.
Although the 1-month mortality rates of both study arms were comparable, many adverse outcomes were
more frequent among patients who underwent PCI in the follow-up period such as cardiac mortality, MI, and
target vessel revascularization. In another larger cohort of 10,141 patients aged 85 years or older with ACS and
multivessel CAD, CABG was more frequently performed compared to PCI, and it was associated with better
survival and freedom from composite morbidity at 3 years follow-up . Thus, it appears that CABG is still
[102]
the best strategy of revascularization in patients with multivessel disease or LMCA lesions even in elderly.

RECOMMENDATIONS
Several foundations and societies such as the ACCF, AHA, European Society of Cardiology (ESC), and the
Society for Cardiovascular Angiography and Interventions (SCAI) have tried to adopt some guidelines and