Ageism camouflaged as medical judgment – why is PCI reserved for more stable elderly ACS patients?

Introduction and aim The role of percutaneous coronary intervention (PCI) in elderly patients with acute coronary syndrome (ACS) remains a subject of ongoing debate. Registries show that older patients are less frequently offered invasive coronary angiography, despite evidence supporting its superiority over conservative management. The aim of our study was to investigate the percentage of patients aged 75 years or older with ACS undergoing PCI and the mortality rates among those who underwent PCI compared with those who did not. Results We included 1036 consecutive patients aged 75 years or older (80.9±4.4) with ACS in our observational study. 488 (47.1%) were female, and 548 were male (52.9%). Myocardial infarction with ST-segment elevation (STEMI) was diagnosed in 40.69% of patients; myocardial infarction without ST-segment elevation (NSTEMI) in 53.33%; and non-stable angina pectoris in 5.98%. PCI was performed in 320 (30.9%) patients: 48.4% with STEMI, 19.1% with NSTEMI, and 19.7% with non-stable angina (p<0.001). During hospitalization, 178 patients (17.2%) died, of whom 33 (10.31%) underwent PCI, while 145 patients (20.25%) did not (p<0.001). In patients with Killip class I at admission, PCI was performed in 36.4%; in 35.9% with Killip class II; in 24.1% with Killip class III; and in 21.4% with Killip class IV (p=0.255). Left ventricular ejection fraction (LVEF) was similar in those with and without PCI (46.8 ± 12.6 vs. 46.1 ± 14.0%, p=0.485). Systolic blood pressure was similar between those with and without PCI (134.0 ± 27.4 vs. 132.6 ± 26.0 mmHg, p=0.5), heart rate was lower in PCI group (78.1 ± 18.9 vs. 86.5 ± 24.3 bpm, p<0.001). Troponin I levels did not differ between PCI and non-PCI groups (2.14 vs. 1.42 ng/mL, p = 0.7), whereas brain natriuretic peptide levels were lower in the PCI group (322.6 vs. 784.4 pg/mL, p < 0.01). CRP levels were lower in the PCI group (23.7 ± 44.0 vs. 38.5 ± 58.7 mg/L, p < 0.001). The estimated glomerular filtration rate (eGFR) was significantly higher in the PCI group than in the non-PCI group (55.2 ± 23.0 vs. 48.3 ± 20.6 mL/min/1.73 m², p < 0.001), as were hemoglobin levels (133.8 ± 77.5 vs. 124.6 ± 37.6 g/L, p = 0.015). LDL cholesterol levels were significantly higher in the PCI group (2.83 ± 1.09 vs. 2.60 ± 1.58, p < 0.05). Conclusions PCI was performed in only a third of our patients, yet it appears highly protective, reducing in-hospital mortality in elderly ACS patients by nearly half. However, there was significant selection bias: patients who received PCI generally had better renal function, higher hemoglobin, lower BNP, reduced inflammation, and were hemodynamically stable. Paradoxically, those without PCI were on higher ischemic risk and might benefit most from revascularization. In elderly patients with ACS, a more thorough risk assessment should be performed when deciding on PCI, with age not being a contraindication.