Table 3. Key points and practical consideration in performing PCI in the very elderly.
| General | • PCI in the very elderly is associated with a decrease in cardiac mortality, significant improvement in cardiovascular well-being, HRQOL and angina burden. |
| • Elective PCI is a safe and effective treatment modality of stable CAD, when clinically indicated. | |
| • The predominant causes of death after all types of PCI in the very elderly may now be non-cardiac in nature. | |
| • Second generation DES compared to BMS reduce the incidence of MI, TVR with no impact on all-cause mortality. | |
| Complications | • Antithrombotic therapy is associated with lower efficacy and higher bleeding rates compared to younger patients. |
| • Reductions in peri-procedural bleeding complications may be achieved by greater use of transradial artery access and pre-procedural bleeding risk assessment with validated scoring systems. Attention to weight and creatinine clearance is required where applicable to ensure correct dose adjustment of certain antithrombotics. | |
| • Withholding of nephrotoxic medications, attention to pre and post-procedural intravenous hydration guided by assessment of LV end-diastolic pressure recording, and judicious use of contrast may help to reduce risk of contrast-induced nephrotoxicity. | |
| Acute coronary syndrome | • Ticagrelor may be a better option than clopidogrel for those with ACS for whom an early invasive strategy is planned, while prasugrel is contraindicated in the very elderly due to higher bleeding risk than clopidogrel. |
| • In those presenting with NSTEACS, revascularization combined with optimal medical therapy is preferred to optimal medical therapy alone. | |
| • In NSTEACS, an early invasive approach is associated with significantly lower risk of death or MI at 6 months compared to those treated with delayed conservative strategy. | |
| • PPCI compared to thrombolysis, improves outcomes in the very elderly presenting with STEMI, and hence is the reperfusion strategy of choice. | |
| • Thrombolytic therapy (particularly when given early) remains a viable alternative when PPCI is not available. |
ACS: acute coronary syndrome; BMS: bare metal stent; CAD: coronary artery disease; DES: drug eluting stent; LV: left ventricular; MI: myocardial infarction; NSTEACS: non-ST elevation acute coronary syndrome; PCI: percutaneous coronary intervention; PPCI: primary percutaneous coronary intervention; STEMI: ST elevation myocardial infarction; TVR: target vessel revascularization.