2005 Vol. 2, No. 1
Since the population worldwide is becoming in-creasingly older and heart disease, at least in much of the world, remains a leading cause of death, it is not surprising that there is growing interest in innovative methods of treatment. Although there has been a rapid growth in experience and technology with percutaneous intervention, little attention has been focused specifical-ly on its use in the elderly. The elderly are generally excluded from clinical trials and, despite becoming an increasing proportion of patients having percutaneous coronary intervention, have to date mostly been studied in small numbers. It is therefore very appropriate that the Journal of Geriatric Cardiology should address a Symposium issue to this subject.
Persons aged 80 and above are the fastest growing age group in the United States population, having in-creased 50% since 1990 and predicted to grow another 25 % by 2020. As this aging population grows, heart dis-ease remains the leading cause of death, accounting for 30% of deaths in the 75-84 age group and 37% for those aged greater than 85 years. Similar trends are apparent throughout much of the rest of the world. As the elderly population increases and technology advances, more and more elderly patients undergo coronary angiography and percutaneous coronary intervention (PCI). In a large se-ries of patients from Northern New England in the US, 4% of all PCI procedures were performed in patients aged 80 or greater between 1989 and 1993, increasing to 8%-9% of all PCI procedures in 1998-2003 ,2'3 In an even larger metanalysis of combined studies, the incidence of PCI in patients aged 75 or older increased between 1990 and 1999 from 12% to 22%.
Background Prior studies have demonstrated that the achievement of faster coronary artery flow following reperfusion therapies is associated with improved outcomes among ST-elevation myocardial infarction (STEMI) pa-tients. The association of patient age with angiographic characteristics of flow and perfusion after rescue/adjunctive percutaneous coronary intervention (PCI) following the administration of fibrinolytic therapy has not been previously investigated. Objectives and Methods We examined the association between age ( ^ 70 years or < 70years) and clinical and angiographic outcomes in 1472 STEMI patients who underwent rescue/adjunctive PCI following fi-brinolytic therapy in 7 TIMI trials. We hypothesized that elderly patients would have slower post-PCI epicardial flow and worsened outcomes compared to younger patients. Results The 218 patients aged ^70 years (14.8%) had more comorbidities than younger patients. Although these patients had significant angiographic improvement in TIMI frame counts and rates of TIMI Grade 3 flow following rescue/adjunctive PCI, elderly patients had higher (slower) post-PCI TIMI frame counts compared to the younger cohort (25 vs 22 frames, P = 0.039) , and less often achieved post-PCI TIMI Grade 3 flow (80.1 vs 86.4% , P = 0.017). The association between age ( ^70 years) and slower post-PCI flow was independent of gender, time to treatment, left anterior descending (LAD) lesion location, and pulse and blood pressure on admission. Elderly patients also had 4-fold higher mortality at 30 days (12.0vs2.7%, P— 0.001). Conclusions This study suggests one possible mechanism underlying worsened outcomes among elderly STEMI patients insofar as advanced chronological age was associated with higher TIMI frame counts and less frequent TIMI Grade 3 flow after rescue/adjunctive PCI.
In ST-segment elevation myocardial infarction ( STE-MI), acute reperfusion of the infarct-related artery (IRA) is the main goal in the early minutes after the patient seeks medical attention. Fibrinolytic therapy (FT) and/or primary coronary intervention (PCI) were proven to be ef-fective in opening the IHA.
Background There is a paucity of information available for clinical decision making applying to the elderly patient population. Therefore, data of percutaneous coronary interventions (PCI) including demographic information on the elderly patients, procedural practices, and outcomes are needed. Objectives and Methods From consec-utive PCIs of participating institutions, demographics data, clinical, angiographic success and adverse clinical out-comes were collected. Standard statistical methods were used to compare crude differences in patient and procedural characteristics across age groups. Results At baseline , the prevalence of comorbid conditions ( renal failure and heart failure) increased with age. Unstable angina or a non-ST elevation MI were the most common indications for PCI across all age groups . Fewer patients ^ 80 years old were undergoing primary PCI and older patients were some-what less likely to receive a lib/Ilia receptor blacker. Slightly more patients ^80 years old underwent a 2-vessel PCI ( consistent with them having more multivessel disease) and these patients were more likely to have an intervention on a Type C lesion . Compared to patients < 50 years old, those aged ^ 70 years old had a significantly increased risk of death , MI, stroke , or vascular complications at the access site . Conclusions This study suggests increasing age is associated with increasing risk for an adverse outcome following PCI. This is in part attributable to case-mix but likely, also related to the changing physiology of aging. Despite the increased risk of the procedure, the clinical suc-cess rate for PCI is quite high and makes it a reasonable alternative for the treatment of CAD in the elderly.
The very elderly patient population ( > 80 years) rep-resents a rapidly increasing segment of our demographics, a consequence of the longer life expectancy and aging of the ' baby boom' generation. Coronary artery disease re-mains a major cause of mortality and morbidity among oc-togenarians with an estimated 30% of them having symp-tomatic heart disease and 50% eventually dying from it.
Objectives To compare the in-hospital outcomes of elderly patients with acute myocardial infarction (AMI) treated by interventional or conservative protocols. Patients and Methods One handred and seventy-six consec-utive patients hospitalized for AMI were involved, including 95 patients underwent emergent percutaneous coronary intervention (PCI) within 24 h after the onset of AMI and 81 patients received conservative non-invasive therapies. Clinical characteristics and in-hospital cardiac events of these two divisions were analyzed. Results In the PCI group, success rate of procedure and lesions was 98.9% and 98.5% , respectively. Procedure related complication were occurred in 6 cases(6.3%) and no patient died during operative procedures. PCI group had a lower in-hospi-tal mortality (11.6% vs 24.7 % , P < 0.05) and overall cardiac events rate (24.2 % vs56.8 % , P < 0.01) com-pared with conservative group. Patients complicated by pump failure at admission in PCI group had a lower mortality compared with their counterpart in conservative group(27.3% vs60.9%, P <0.05). The average hospital dura-tion between the two groups was no significant differences. The coronary care unit (CCU) duration of the PCI group was less than that of conservative group (4±5dvs8±5d, P < 0.05). Conclusions In elderly patients with AMI, interventional treatment can significantly decrease the in-hospital mortality and cardiac events rate compared with conservative treatment, thus gains a better short-term outcome.
Elderly patients constitute a growing part of the ST segment elevation myocardial infarction (STEMI) popula-tion. By nature of their co-morbid conditions and other factors, elderly patients have a higher absolute rate of mortality and risk of complications from STEMI. It is for this very reason that rapid and complete optimal reperfu-sion therapy is essential. Unfortunately, little research has focused exclusively on elderly STEMI patients, and therefore what defines optimal reperfusion therapy in eld-erly patients is unclear. On the contrary, randomized clinical trials often specifically exclude patients older than age 75 because of their increased risk for complica-tions. The increased absolute rate of mortality and com-plications is precisely what often prevents physicians from attempting early, aggressive management of patients.
Objective To evaluate angiographic and clinical outcomes of ^ 20mm long stents or overlapped stent implantation in diffuse coronary lesions for octogenarians, in comparison with patients under sixty. Methods Two groups (Group 0: 47 lesions in 44 octogenarians, aged 81 ± 3 years; Group Y: 64 lesions in 58 patients under sixty, aged 54 ± 4 years) were compared with a 6-month follow-up. Results Success rate of the procedures was 100%. None had in-hospital major adverse cardiac events (MACE). There was no significant difference in angiographic restenosis between the groups at follow-up (Group 0 vs Group Y, 29.8% vs 26.6% , P = NS). The revascularization of target vessel and MACE was less in Group Y, but these showed no statistical significance (15.6% vs 23.4% and 20.7% vs 25.0%, respectively). Conclusions Long stent implantation for diffuse coronary lesions in octogenarians appears safe and feasible, with high procedural success and favorable long-term outcomes.
While the elderly represent one of the highest-risk patient subsets among the growing population of patients undergoing percutaneous coronary intervention ( PCI), elderly patients are often under-treated with revasculariza-tion therapies. Doubts regarding a lack of durable benefit of PCI in elderly patients often lead physicians to pursue conservative management strategies, despite the potential to derive greater absolute and relative benefits through re-vascularization. The reluctance to revascularize elderly patients is partly related to the greater risk of immediate complications, greater lesion complexity, and a higher prevalence of diffuse and multivessel disease-all factors that render the performance of PCI more difficult.
Objective The management of hypertrophic obstructive cardiomyopathy is not well-defined in the elderly. Medical therapy with (3-blockers and calcium-channel blockers are the mainstay therapy for symptomatic patients. Myomectomy is usually reserved for patients who fail medical therapy. Alcohol septal ablation has been recently in-troduced as an alternative therapy. Patients and Methods Ninety-five patients older than 65 years of age were included. All patients have completed one year of follow-up. The mean age was 72 ± 5 years, 47 patients were fe-males , 10 patients with history of hypertension. Results The mean rise in CK post alcohol ablation was 1052 ± 430 IU. The mean NYHA class decreased from 2.9±0.6tol.2±0.5 ( P < 0.001). The exercise duration on tread-mill testing increased from 328 ± 260 s to 349 ± 39 s. The mean resting left ventricular outflow tract gradient de-creased from 65 ± 37 inmHg to 16 ± 29 inmHg at one year. One patient died in the hospital after coronary artery by-pass grafting that was done subsequent to spiral dissection of the left anterior descending artery during ablation. Thir-teen patients developed complete heart block immediately after ablation requiring pacing therapy. Conclusions Al-cohol septal ablation seems to be an effective alternative therapeutic option for elderly patients with hypertrophic ob-structive cardiomyopathy. Larger studies with longer follow-up are needed.
Hypertrophic cardiomyopathy (HCM) is a common genetic abnormality that can occur in as many as 1 in 500 persons. Researchers have found multiple mutations in 10 different sarcomeric proteins such as myosin heavy chain and tropomyosin can cause this disease. HCM is the most common monogenic cardiac disorder and the most common cause of sudden cardiac death (SCD) in children and ad-olescent. Patients with obstructive HCM typically com-plain of dyspnea, angina, nearsyncope and/or syncope on exertion. Patients with non-obstructive HCM rarely pr-esent with these symptoms or the symptoms are milder. At present, the risk factors for SCD are young age, syncope, a malignant family history, sustained ventricular tachycar-dia in electrophysiologic testing or holler monitoring and severe hypertrophy with significant left ventricular ( LV) outflow obstruction.
Objectives Early and accurate diagnosis of peripheral atherosclerosis is of paramount importance for global management of patients with known coronary artery disease (CAD), especially in the elderly. We sought to evaluate the prevalence and clinical relevance of significant abdominal vessel stenosis or aneurysm (AVA ) in patients undergo-ing coronary angiography. Methods Medical records of consecutive > 75-year old patients who underwent coronary angiography at two public institutions over a 12-month period were evaluated. Angiographic results of patients who un-derwent coincident diagnostic abdominal aorta angiography to evaluate abdominal vessels on the basis of clinical and angiographic criteria were analyzed. Results During the study period, AVA was found in 90 (35.7%) of 252 con-secutive patients (185 males, mean age 79 ±5.8 years), renal artery stenosis in 13.1% of cases (33 patients), aort-oiliac artery disease in 13.7 % (35 patients), and aortic aneurismal disease in 8.9% (22 patients). Logistic regres-sion analyses revealed > 3-vessel CAD (odds ratio [OR] :9.917, P = 0.002), and > 3 risk factors (OR: 2.8, P = 0.048) as independent predictors of AVA . Conclusions Aged patients with multivessel CAD frequently have a high risk profile and multiple vascular atherosclerotic distributions, suggesting the usefulness of a more global and compre-hensive cardiovascular approach in aged patients.
The World Health Organization estimates there are over thirty-two million major atherothrombotic events oc-cur worldwide each year with nearly seventeen million di-rectly attributable deaths.' Atherothrombosis as the name refers to blood clot formation within an arterial vessel. It may occur de novo, usually over an atherosclerotic seg-ment of the vessel, or embolised from a proximal source." These clots cause the blood vessel lumen to be-come totally or sub-totally occluded and, depending on the site and supply, lead clinically to unstable angina and myocardial infarction, ischemic strokes or leg claudica-tion. Acute myocardial infarction ( AMI) alone account for 25% of all deaths in the United States and is the leading cause of death in the world including many of the developing countries.3 It is of little suiprise therefore that from the cardiologists' standpoint, the bulk of our work whether as researchers or clinicians have been channeled towards the prevention, regression or at least delaying the process of atherothrombosis and minimizing its risk of re-currence. Yet we must be mindful that atherothrombosis is a generalized and progressive disease. Indeed over a quarter of patients with vascular disease would involve 2 or more vascular beds in their lifetime.4 For example, patients with a first stroke or peripheral arterial disease (PAD) has a 2 to 4-fold increased risk of AMI. Patients who have had an AMI are themselves at 5-fold increased risk of a further heart attack. The life-expectancy of pa-tients with a history of stroke, PAD or myocardial infarc-tion is also reduced.4'5 But to screen all patients with suspected cardiovascular disease for concomitant peripher-al disease would lead to unnecessary risks from longer ra-diation exposure, higher amount of contrast used and costs. Hence the original article by Rigatelli et al in this issue addresses an important issue on which patient scheduled for coronary angiogram should also undergo aorto-iliac studies.6 Indeed the clinical issue of whether it is justified to perform additional scans is also highlighted here.
Elderly patients with acute myocardial infarction have not been specifically studied in the context of a large randomized clinical trial. Estimates of the efficacy of available treatments are gleaned from subset analyses of clinical trials, retrospective analysis and single center experiences. In western countries the population is aging and a disproportionate number of myocardial infarctions occur in the elderly. Usage of appropriate therapy in this age group is becoming increasingly important given the potential for benefit but also the potential for harm. Recent publi-cations have found steady improvement in outcomes in the elderly population utilizing contemporary interventions.
Objective To assess the diagnostic value of chest radiographs in patients presenting to a busy inner-city Emer-gency Department with subsequently proven acute aortic dissection. Methods A retrospective review of initial chest radiographs and charts of patients with the confirmed diagnosis of acute aortic dissection was done for a period of 5 years from 1998 to 2003 . A comparison was made between the initial readings of chest radiographs prior to con-firmation of the aortic dissection, and a retrospective review of the same radiographs by two board-certified radiolo-gists with special attention to the classic findings of acute aortic dissection identifiable on plain films. Results The charts of nine patients (four men, five women) with proven acute aortic dissection were reviewed. All nine pa-tients were suspected of having acute aortic dissection based on presenting history and symptoms of chest pain (66%), migratory pain (89% ), back pain (89% ), and the abruptness of onset of pain (89% ). Initial plain por-table chest X-rays were obtained in the Emergency Department in all nine patients. Six of nine (67%) radiographs were read as normal, while three (33%) demonstrated a widened mediastinum ( > 8.0cm), two (22%) showed an abnormal aortic contour, with one (11%) displaying an apical cap. Confirmation of the diagnosis was obtained with either a spiral CT angiogram or transesophageal echocardiography (TEE). All nine plain radiographs were retrospec-tively reviewed by two board-certified radiologists aware of the diagnosis of acute dissection without a change in the readings. Conclusions Plain portable chest radiographs are of limited usefulness for the screening of acute aortic dissection. Further radiologic evaluation should be dictated by the clinical presentation and an awareness of the low sensitivity of portable chest X-rays.
Acute aortic dissection is a serious condition in eld-erly patients and may become fatal rapidly if left undiag-nosed and untreated. As pointed out by Welch et al1 chest radiography is a screening test for this condition by detecting these signs such as widening mediastinum, blurring of the aortic knob, left apical cap, etc. Unfortu-nately these signs on chest radiography may not be sensi-tive enough to detect acute aortic dissection.1'2 There-fore, if patients have high clinical likelihoods of ihe aortic dissection including old age, crushing chest pain, hyper-tension, pulse deficit, known history of thoracic aneu-rysm, or Marfan' s syndrome, etc, further diagnostic test is required to exclude this deadly disease even normal chest radiography.2'3 Other imaging modalities include aortography, transesophageal echocariogrpahy ( TEE ) , magnetic resonance imaging ( MRI) , or computerized to-mography (CT). "'? Currently, aortography is not routine-ly performed to diagnose this condition because it may worse the situation if the catheter is placed into the false lumen. Noninvasive modalities have increasing role be-cause they can detect dissection very accurate and provide the information of the wall and near by structures. " This is so important because it has been recognized that acute aortic syndrome is a spectrum of the diseases including acute aortic dissection, penetrating aortic ulcer, intramu-ral hematoma, and aortic rupture.4' 5 Each imaging mo-dality has strength and weakness for detecting this syn-drome. Transesophageal echocardiography provides ade-quate diagnostic accuracy, evaluates the involvement of aortic valve, determines cardiac function, and importantly can be performed at the bedside in this sick individual, however, the distal part of ascending thoracic aorta and proximal aortic arch area is a blind spot in a number of patients due to the air-filled trachea and left mainstem bronchus interposed between the esophagus and this part of the aorta." The false positive results may be due to reverberation artifacts, calcified plaque, therefore, other imaging modality may help to improve the detection if TEE is nondiagnostic. Magnetic resonance imaging is known to be an excellent modality to determine these con-ditions with high accuracy.3'4'6 The extent of the disease can be completely assessed with MR angiography and car-diac and valve function can be assessed as well. Due to large field of view, the involved surrounding structure and aortic wall can be assessed. Unfortunately, the examina-tion is in a closed space and if patients are in critical con-dition, it may not be an ideal situation due to safety con-cern. The MRI examination is contraindicated in patients with cardiac pacemaker, automatic implantable cardio-verter-defibrillators, intracranial aneurysm clips, or oto-logic implants, etc." Recently, the development of multi-detectors CT scanner allows very fast image acquisition and provides information in aortic pathology, as well as cardiac function and coronary artery disease. Coronary ar-tery involvement from dissection or existing significant coronary arterial stenoses can be determined as well with CT examination. " This will improve and shorten diag-nostic process and patient may be omitted from diagnostic coronary angiography to exclude significant coronary arte-rial stenoses prior to surgery if needed.8'1 '" Cardiac CT has been evolving to be utilized for the evaluation of chest pain patients presented in emergency unit because it can detect various causes of chest pain including acute aortic syndrome, coronary artery disease, pulmonary embo-lolistn, or pneumothorax, etc.9 One important limitation is that CT examination requires iodinated contrast which may not be used in some patients who have concomitant renal failure.
Since the introduction of coronary angiography in 1959,' a new "gold standard" examination became avail-able for the evaluation of coronary artery disease. The tra-ditional approach for transcatheter coronary revasculariza-tion since the introduction of percutaneous transluminal coronary balloon angioplasty (PTCA) by Gruentzig in September 1977 had been visual assessment of the lesion as well as the results of the intervention by coronary an-giography ." Refinements in the technology and techniques for mechanical revascularization in the 1980s lead to ex-plosion of " new devices mainly in an attempt to attenuate the major limitation of PTCA related restenosis. Various pharmacological agents have shown promising results in reducing the rate of restenosis, including monoclonal anti-bodies against the glycoprotein receptors on platelet cell surfaces." Yet restenosis continues to be the "Achilles heel" of transcatheter interventions. Restenosis occurs in 30% to 50% of transcatheter coronary procedures. The natural history and pathophysiology of restenosis are still incompletely understood.4 Certain clinical, angiographic and procedure-related variables have been identified as risk factors for restenosis.5'6 Coronary stenting, especial-ly the recent development of drug-eluting stents has been proven to be effective to prevent restenosis to some ex-tent. Restenosis remains still exist. Recent studies have shown that assessment of the lesion length using intravas-cular ultrasound (IVUS) in order to fully cover the lesion for a drug-eluting stent is of clinical importance.