Contemporary Outcome of Cardiac Catheterization in Nonogenarians

To the Editor: Mean life expectancy rose from 21 years in the 16th century1 to 81.6 years for a newborn female in Germany in 2006.2 In the aging population of modern Western societies, patients aged 75 and older account for approximately 30% of hospital admissions for acute myocardial infarction (MI), and patients aged 80 and older constitute the fastest-growing segment of the U.S. population.3 Nevertheless, only a minority of less than 10% of all patients enrolled in randomized clinical trials of acute MI were aged 75 and older,4,5 and little is known about the safety and efficacy of contemporary coronary catheterization and percutaneous coronary intervention performed in nonogenarians. From January 2003 through December 2005, 32 nonogenarians out of 14,892 consecutive patients undergoing cardiac catheterization were included in a registry. The control group was established by collecting data of 100 patients selected as a representative random sample by picking every 180th patient of the entire study population. The following parameters were assessed. Patient-related factors: age, sex, arterial hypertension, peripheral artery disease, hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease, previous MI, previous percutaneous intervention (PCI), previous CABG, and cardiogenic shock Procedure-related factors: number of diseased epicardial arteries, location of the culprit lesion, type of treatment, ejection fraction (EF), and emergency procedure Complications: vascular complications, acute renal failure, and in-hospital mortality. Differences between groups were analyzed using the Student t-test, chi-square test, or Fischer exact test as appropriate. Nonogenarians were more likely to have comorbidities (e.g., diabetes mellitus, chronic obstructive pulmonary disease) but less likely to have high levels of serum cholesterol than controls. Approximately 45% of the study population had a previous history MI, PCI, or CABG. Multivessel disease was more frequent in nonogenarians than in the control group (58% vs 44%, P=.01); the majority (84%) of nonogenarians had at least one coronary artery stenosis. The most frequent indication for coronary angiography in the study group was acute coronary syndrome (85%). The nonogenarians were more likely to have evidence of hemodynamic compromise on presentation (cardiogenic shock 15% vs 2%, P=.003). Nonogenarians diagnosed with acute coronary syndrome were transferred to a tertiary PCI center significantly faster than the younger control group. Complex lesions that required at least one long (≥20 mm) or multiple stents (≥2 stents) were present in 47% of the nonogenarians. Mortality in nonogenarians (13%) was significantly higher than in the control group (P=.003). The incidence of relevant complications was low in both groups (Table 1). Nonogenarians in this series had substantially more comorbidities and cardiac risk factors than controls, consistent with data from previous investigations.6–9 Because risk factors in nonogenarians are more prevalent, more-extensive atherosclerosis with multivessel disease (58%) and complex lesions (47%) were encountered. Nonogenarians in this series were sent to coronary angiography almost exclusively with the diagnosis of acute coronary syndrome. In the case of acute coronary syndrome, nonogenarians were transferred much faster from the rural hospital to the PCI center than patients younger than 90. This is in contrast to finding of other authors, showing that patients aged 80 and older had access to invasive procedures rather late.8 Several studies demonstrated a curvilinear relationship between mortality after elective coronary angiography or coronary intervention and age, ranging from approximately 0.5% for patients younger than 55 to approximately 5% for patients aged 85 and older.7 Previous multivariate logistic regression analyses in the literature revealed independent risk factors for in-hospital death for very old patients: cardiogenic shock, MI without shock, left ventricular ejection fraction less than 35%, renal insufficiency, age 85 and older, and diabetes mellitus.6,9 Because approximately 85% of the nonogenarians in the current series had one or more indicators of clinical instability or worse prognosis, they had an in-hospital mortality rate of 13%. This is comparable with data in the Euro Heart Survey on coronary revascularization, with an in-hospital mortality of 8% in patients aged 75 and older with ST-elevation MI treated using PCI.10 In an MI registry of more than 8,000 octogenarians (mean age 84), in-hospital mortality after primary PCI was 14%.7 Cardiac catheterization, including interventional procedures, is often felt to be contraindicated in patients aged 90 and older. The data from the current study demonstrate acceptable complication rates and in-hospital mortality, indicating that this rapidly expanding patient population should not be refused access to cardiac catheterization based merely on their age. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: Marc-Alexander Ohlow: concept and design, acquisition of data, analysis and interpretation of data, drafting of the letter, final approval of the version to be published. Maria-Anna Secknus, Hubertus von Korn, Andreas Wagner, Jiangtao Yu, and Bernward Lauer: analysis and interpretation of data, revising of the letter, final approval of the version to be published. Sponsor's Role: None.