Primary PCI in a nonagenarian: an uncommon predicament

Abstract

Myocardial infarction in a nonagenarian is a morbid cardiac illness that can lead to significant mortality unless properly dealt with management aspects. Many comorbid or family-related issues might be part of holdbacks in management of such a group of patients. Hence, myocardial infarction in a nonagenarian where intervention is better treatment option forms an uncommon combination and has many preprocedural, periprocedural and postprocedural difficulties related to multiple issues. Here, we present a case of nonagenarian who presented with extensive anterior wall MI and was successfully dealt with primary percutaneous coronary intervention despite periprocedural and intraprocedural difficulties.

Background

Elderly population form the major growing subset in future days. Also, the comorbidities in them when added to cardiac disease will offer a real challenge in management of such group of patients. In nonagenarian patients with myocardial infarction, interventional management definitely benefits with respect to bleeding risks. Primary percutaneous coronary intervention (PCI) being done in a nonagenarian is quite uncommon considering the incidence, comorbidities, family decisions and procedure-related challenges. Here, we report a case of nonagenarian who presented with anterior wall ST elevation myocardial infarction and was successfully treated with primary PCI. Also, discussion is being done regarding treatment options, including difficulties at multiple levels.

Case presentation

A 94-year-old man with no diabetes mellitus, hypertension and prior cardiac or renal disease presented to chest pain unit with retrosternal chest discomfort of acute onset and 5-hour duration. Also, there was associated profuse sweating. He had no associated syncope or palpitations. He denies any recent prolonged travel or swelling of legs. Clinical examination showed well-maintained sensorium, normal haemodynamic parameters with mild tachycardia and no features of overt heart failure.

Investigations

ECG at admission showed sinus tachycardia, ST elevation in leads I, aVL, V1–V6 suggestive of extensive anterior wall myocardial infarction with reciprocal ST depression changes in inferior leads (figure 1). Intervals were normal. The troponin T level was elevated at 48.8 pg/mL and CK-MB level was 8 ng/mL. Chest radiography was non-contributory. Echocardiography performed at admission showed moderate LV systolic dysfunction with hypokinesia in left anterior descending (LAD) artery territory. Hence, he was a case of ST elevation myocardial infarction.

Figure 1.

ECG showing sinus rhythm with diffuse ST elevation in anterior and lateral leads (I, aVL and V1–V6) with reciprocal ST depressions in inferior leads (II, III and aVF).

Differential diagnosis

Tip: please do not list diagnoses. We want to understand how the final diagnosis was teased out. This is often the most important section and needs to be substantially discussed. All working diagnoses need to be substantiated.

Treatment

The options of management and risks associated were discussed in detail with patient and family members following which he was planned for primary PCI. Coronary angiography was performed through right radial artery access and it showed normal left main; LAD artery was calcific vessel and occluded after a short stump (figure 2 and video 1); circumflex artery was normal; and right coronary artery had occlusion in mid vessel (distal being filled by bridging collaterals and also left-sided collaterals). Hence, it was decided to intervene on LAD arerty as it was the culprit vessel.

Figure 2.

Selective left coronary angiogram showing occluded left anterior descending artery just after ostium in RAO cranial view (A) and LAO caudal view (B).

Video 1.

Download video file ^{(1,019.1KB, mp4)}

DOI: 10.1136/bcr-2020-237650.video01

During the procedure, we had difficulties at multiple levels. Initially via radial access, there was arterial loop at axillary artery level which was crossed using 0.035-inch glidewire. During percutaneous transluminal coronary angioplasty to LAD that was performed using 6F guiding catheter, vessel was wired using 0.014-inch coronary guidewire with difficulty as it was tight lesion with wall calcium (both superficial and deep). Following wiring, lesion dilatation was done in graded way with 1.5 mm, 2.0 mm and 2.5 mm diameter balloons and it was a calcific lesion (figure 3A). The 2.5-mm balloon was taken across the lesion with help of guide extension catheter. It was decided to use two stents as lesion was longer and calcific. Stents were tracked using guide extension catheter within the guiding catheter and lot of manipulation (figure 3B and video 2). Finally, after stent deployment, post-dilatation was done with adequate balloon. Final result was TIMI III flow with no complications (figure 3C and video 3). Final contrast volume used was 80 mL of iodixanol.

Figure 3.

Angiogram of left system in RAO cranial views. (A) shows after balloon dilatation. (B) shows stent being advanced with guide extension catheter support—arrow directed to the extension catheter. (C) shows final image after stent deployment.

Video 2.

Download video file ^{(1.5MB, mp4)}

DOI: 10.1136/bcr-2020-237650.video02

Video 3.

Download video file ^{(1.2MB, mp4)}

DOI: 10.1136/bcr-2020-237650.video03

Outcome and follow-up

During hospital stay, patient was well and no arrhythmias were noted; his left ventricular ejection fraction was 37%. His serial cardiac enzymes were troponin T level of 120 pg/mL and CK-MB level of 10 ng/mL being at peak levels. There was no evidence of contrast-induced nephropathy on serial blood tests. Patient improved and was discharged on fourth day of procedure with guideline directed medical treatment and cardiac rehabilitation protocol.

Discussion

Cardiovascular disease in nonagenarians is quite common and adds up to the morbidity and mortality. Also, atypical presentations, associated comorbidities, neurological problems involving memory and delayed decision-making will add up to the care of the patient, including invasive strategies. Most clinical trials exclude patients aged >75–80 years as prolonged follow-up may be compromised by life expectancy. The first case report of primary PCI in a nonagenarian was published in 2002.¹

The problems faced during primary PCI for nonagenarian patients include loading antiplatelets, access site bleeding (being less with radial access), contrast nephropathy, comorbidities and delay in decision-making by family, including mental status of patient for decision and consent in this age group. With respect to intervention per se, there are difficulties at multiple levels that include access site selection, vascular tortuosities, coronary wall calcium, tracking of balloons and stents. In extreme cases, there might be need for accessory hardwares, including guide extension catheter and rota-ablation strategy. In our case, we used guide extension catheter for extra support.

Papillary muscle rupture, myocardial oedema and intramyocardial haemorrhage are common autopsy findings in elderly patients with myocardial infarction treated with thrombolysis. Among the available reperfusion therapies, PCI seems to be beneficial compared with thrombolysis. These data come from the subgroup of elderly patients participated in PAMI-l, GUSTO-IIb and DANAMI-2 studies. There are no randomised studies to compare balloon angioplasty versus PCI with stenting in very elderly patients with STEMI. A subgroup analysis from the CADILLAC study showed that patients over 65-year-old randomised to stent implantation did better than angioplasty alone.²

Among primary PCI in 55 octogenarians, Laster et al reported 30-day mortality rate of 67% for patients with cardiogenic shock on presentation and of 10% for patients without cardiogenic shock. According to Valente et al, among 88 patients ≥85 years of age who underwent primary PCI, the respective figures were 90% and 7.7%.³

In a large series, Goel et al⁴ discussed regarding temporal trends in nonagenarian PCI. Among STEMI, the overall in-hospital mortality after PCI and conservative management was 16.4% and 33.5%, respectively. After multivariable risk adjustment, PCI was associated with lower in-hospital mortality. PCI was also associated with lower incidence of in-hospital stroke and shorter hospital stay, whereas vascular complications were expectedly higher among PCI patients. Over 10 years of study period, there was no change in adjusted rates of in-hospital mortality; major bleeding and vascular complications were unchanged, whereas the average length of stay decreased.

In a large study of primary PCI among nonagenarians, Helft et al⁵ found significant increased hospital mortality among nonagenarians in both univariate and multivariate analysis despite similar angiographic success rates as compared with those with less than 90 years of age. The factors for in hospital mortality were studied in detail by Ipek et al and found that acute stent thrombosis, anterior myocardial infarction, heart failure, low ejection fraction of less than 30%, ventricular arrhythmias and multivessel disease were the independent risk factors among octogenarian patients after primary PCI.⁶ According to Koutouzis et al, primary PCI may be feasible in nonagenarians, but is accompanied by high mortality rates, especially in patients with anterior infarct location and/or severely depressed ventricular function on presentation.⁷ Our patient had risk factors of only anterior wall involvement with double vessel disease and hence was slightly a low risk candidate. Also, our patient had significant symptom relief after establishing flow in the vessel and gradually was made ambulant during hospital stay. On follow-up, he is doing well without any anginal symptoms.

According to Petroni et al whose study was of long follow-up, primary PCI in nonagenarians was feasible through a transradial approach. It was associated with a high rate of reperfusion of the infarct-related artery and 53% survival at 1 year.⁸ Also, Rigattieri et al showed that primary PCI can be performed with high success rate and with an acceptable bleeding risk, even when aggressive antithrombotic drugs are given.⁹

Nonagenarians being risky group of population with many aspects definitely lead to a difficult decision-making at times of emergencies especially myocardial infarction with cardiac perspective along with frailty issues. Though specifically symptom relief has not been considered as an endpoint in the available limited studies in nonagenarians with myocardial infarction, there is definitely beneficial role of primary PCI with respect to mortality, complications, ventricular function and bleeding rates. The outcome of primary PCI in very elderly population is favourable and should be offered to nonagenarian patient presenting to tertiary-care hospital with well-equipped Cath lab and experinced staff.

Patient’s perspective.

It was difficult for me to take decision as I was very old but situation, including procedure, was successfully handled by the team. I was perfectly symptom-free after procedure and was discharged in a stable situation.

Learning points.

• Primary percutaneous coronary intervention (PCI) still remains the best option in nonagenarians presenting with STEMI considering risk–benefits.

• Comorbidities and frailty issues must always be considered during decision-making in STEMI patients over 90 years of age.

• Postprocedural rehabilitation care has also an equivalent role in nonagenarian patients undergoing primary PCI.