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Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29 Page 11 of 17

Figure 1. Summary of the 2014 AHA/ACC recommendations for the management of old patients (≥ 75 years of age) with non-ST-
elevation acute coronary syndromes. ACC: American College of Cardiology; AHA: American Heart Association; ACS: acute coronary
syndrome; CABG: coronary artery bypass graft; COR: class of recommendation; LOE: level of evidence; DM: diabetes mellitus; PCI:
percutaneous coronary intervention

recommendations based on the latest available clinical trials and observational studies in order to make the
decision of performing PCI on older patients clearer and more evidence-based. The management of older
population with CAD should be patient-centered and the decision whether to direct the patient toward
reperfusion therapy or to adopt a less invasive and more conservative management should not be taken
solely based on the patient’s age. On the other hand, the patient’s preferences, life expectancy, all his other
co-morbidities, and functional status should be considered before denying or recommending PCI. A report
from the ACCF, AHA, and SCAI stated that the PCI clinical benefits in younger and older population are
comparable. However, the increased risk of some adverse outcomes in elderly like bleeding events and stroke
should be taken into consideration . The latest ESC guidelines for management of patients presenting with
[103]
acute STEMI have also emphasized maintaining a high level of suspicion when dealing with any elderly
presenting with atypical symptoms to avoid any delay in the diagnosis and reperfusion therapy . Primary
[104]
PCI should not have an upper age limit and any patient can be qualified for PCI based on his individual
circumstances. The transradial approach was also recommended whenever it is possible in these patients.
In addition, dosing of thrombolytic therapy should be adjusted carefully according to the patients’ kidney
function, other medications, and comorbidities. The ACCF and AHA have also recommended the use of
bivalirudin, instead of a GP IIb/IIIa inhibitor plus unfractionated heparin, both initially and at PCI in elderly
presenting with non-ST segment elevation ACS, as the former is associated with lower bleeding risks. However,
the dosing of all the medical therapy must be modified according to the patients’ body weight and creatinine
clearance . They have also stated that CABG can be preferred over PCI for appropriate candidates, especially
[6]
those with diabetes mellites and multivessel disease with SYNTAX score of more than 22 [Figure 1].

CONCLUSION
There are several factors that render PCI a more challenging procedure among the elderly such as more
complex coronary lesions, co-morbidities, frailty, and hematological alterations. Historically, PCI clinical
outcomes have been demonstrated to be worse among older populations compared to their younger
counterparts. Moreover, the participation of the elderly in the clinical trials that investigated different aspects
of PCI has been markedly under-represented which created a vague state of decision making capability that