Coronary interventions in the elderly

Cardiovascular disease (CVD) is the leading cause of morbidity, mortality, and reduced quality of life in western cultures. Elderly patients, usually defined as those aged 65 years or above, are particularly affected; since they are the fastest growing segment of the population, the absolute prevalence of CVD will therefore increase further. Among cardiovascular diseases, coronary artery disease is—by quantity and quality—the most prominent one, a fact that emphasises the relevance of coronary interventions in these patients. With regard to percutaneous coronary intervention (PCI), many studies of the pre-stent era had rather disappointing results for elderly patients, lower success rates and frequent complications being the most prominent problems. In the meantime, because of improvements in interventional techniques, particularly the routine use of stents, outcomes have improved continuously while complications have decreased. A particularly striking example of this phenomenon are studies with recruitment periods lasting several years, in which significant improvements over time could be observed even within the individual trials. However, since most interventional studies focus on patients aged 50–65 years, scientific evidence regarding the interventional treatment of the elderly is not as good as for younger patients. For this and other reasons, many physicians are still reluctant to suggest any invasive measure for elderly patients with known or suspected coronary artery disease. An important insight from recent studies is the heterogeneity of risk observed for elderly patients. While peri-interventional mortality in elective PCI may be as low as 1% in the absence of risk factors, mortality increases exponentially in emergency situations involving multi-morbid patients, rising to more than 20%. The treatment of the elderly in urgent settings is complicated by several problems: the elderly more often present with acute coronary syndromes, have longer intervals from the onset of symptoms to presentation, frequently complain of atypical symptoms, and frequently present with …