Review

Percutaneous
Coronary Intervention
in Elderly Patients
Is It Beneficial?

Madhan
Shanmugasundaram, MD

Persons aged 65 years or older, often referred to as the elderly, are a rapidly increasing
population in the United States. Cardiovascular disease is the most common cause of
morbidity and death in this age group, and acute coronary syndrome accounts for a significant proportion of the deaths. Percutaneous coronary intervention is a well-established
treatment for acute coronary syndrome and symptomatic coronary artery disease. However, community studies have shown that elderly patients are less likely to undergo revascularization, perhaps due to a treatment-risk paradox: elderly patientsat higher risk of
morbidity and death from acute coronary syndromeare denied revascularization even
though they are likely to benefit from it. Age alone is one of the many reasons why percutaneous coronary intervention is avoided in elderly patients. This review examines past
clinical trials and the existing evidence that supports performing percutaneous coronary intervention in elderly patients. (Tex Heart Inst J 2011;38(4):398-403)

C
Key words: Age factors;
angina, unstable/complications/prevention & control/
therapy; attitude of health
personnel; cardiovascular
diseases/complications/
mortality/prevention &
control/therapy; heart
catheterization/utilization;
health services for the aged/
standards; myocardial revascularization/utilization;
randomized controlled trials
as topic/statistics & numerical data; risk factors; survival
analysis; treatment outcome
From: Department of Internal Medicine, University
of Arizona College of Medicine, Tucson, Arizona 85724
Address for reprints:
Madhan Shanmugasundaram, MD, Department of
Internal Medicine, University of Arizona College of
Medicine, 1501 N. Campbell
Ave., P.O. Box 245040,
Tucson, AZ 85724
E-mail:
smadhan13@gmail.com
2011 by the Texas Heart
Institute, Houston

398

ardiovascular disease is the most common cause of morbidity and death in

persons aged 65 years and older, and its incidence increases with age. Older
adults are a rapidly increasing population in the United States: by the year
2030, 1 of every 5 individuals might be older than age 65 years.1 The terms elderly
and older adults usually refer to persons older than 65; however, experts in the field
of geriatrics suggest that a more functional definition is necessary to characterize this
subgroup of the adult population.2 Acute coronary syndrome (ACS) accounts for approximately one third of all deaths in elderly patients in the U.S.,3 and the management of those with coronary artery disease (CAD) poses a challenge because multiple
comorbidities might limit treatment options. Unfortunately, there is a paucity of evidence to guide therapy in this population, primarily because advanced age has been
an exclusion criterion in most clinical trials.
Percutaneous coronary intervention (PCI), a well-established treatment for ACS
and for chronic stable angina refractory to medical therapy, has lowered cardiovascular
morbidity and mortality rates in carefully selected patient populations. Community
studies have shown that elderly patients are less likely to undergo PCI, mostly because
some earlier studies from the pre-stenting period showed lower success rates and increased complication rates in these patients. Furthermore, elderly patients often present
with ACS, delay seeking treatment, and have increased rates of atypical symptoms,
nondiagnostic electrocardiograms, and multiple comorbidities. Despite these problems, evidence from the medical literature shows that PCI may be a viable treatment
option for elderly patients.
Literature Search

The purpose of this clinical review was to examine randomized clinical trials that
have evaluated the safety and efficacy of PCI treatment in elderly patients. A PubMed
search was performed with use of the terms elderly, older adult, percutaneous coronary intervention, and percutaneous transluminal coronary angioplasty. Highquality randomized controlled trials, subgroup analyses of randomized trials, and
retrospective studies aimed at evaluating the efficacy of PCI in elderly patients in different clinical situations were included in this review. The citation lists from these publications were also examined for further relevant material. When appropriate, some
review articles or websites were included. Finally, since individuals age at varying rates
because of differences in physical health, lifestyle, and socioeconomic factors, calen-

Benefits of PCI in Elderly Patients

Volume 38, Number 4, 2011

dar age is an arbitrary point of reference.2 This review

defines persons 65 years and older as elderly.
Why is Percutaneous Coronary Intervention
Avoided in the Elderly?

For a variety of reasons, the in-hospital mortality rate

after PCI tends to be higher in elderly patients than
in younger patients. In several trials, advanced age was
associated with worse short-term prognosis and higher rates of PCI-related complications.4-6 Elderly patients
are often frail and their CAD extensive, which increases morbidity and mortality rates after PCI. The technical feasibility of performing PCI in elderly patients has
been questioned, especially because severe coronary calcification and tortuous vascular anatomy make coronary and vascular approaches difficult. Elderly patients
often have multiple comorbidities, including chronic kidney disease, which increases the risks associated
with PCI. Physiologic considerations might affect the
outcome after PCI, including the prolonged effects of
risk factors on the vascular system that lead to more extensive patterns of atherosclerosis in the coronary arteries and other vascular beds; increased vascular stiffness
with aging, which leads to systolic hypertension; left
ventricular hypertrophy; and decreased left ventricular
function. Myocardial diastolic function becomes impaired with aging, and endothelial dysfunction is more
prevalent. It is unclear how these physiologic effects of
aging relate to the outcome of PCI.

Evidence Supporting Percutaneous

Coronary Intervention in
Specific Clinical Situations

increased risk of stroke and intracranial hemorrhage in

the elderly patients, neither of these events occurred in
the PCI group.11 The Global Use of Strategies to Open
Occluded Coronary Arteries in Acute Coronary Syndrome (gusto IIb) trial showed a strong trend toward
lower 30-day mortality rates with PCI than with fibrinolytic therapy in elderly STEMI patients (age 70
yr).12 The Danish Multicenter Randomized Study on
Fibrinolytic Therapy versus Acute Coronary Angioplasty in Acute Myocardial Infarction-2 (danami-2) trial13
compared STEMI patients transferred for PCI within
2 hours from symptom onset to patients who received
on-site tPA. A subgroup of patients aged 63 years who
underwent PCI had a more significant reduction in 30day death, MI, or stroke than did the patients who were
given tPA.13 Smaller trials also showed that in elderly
patients (age 65 yr) with STEMI, PCI resulted in a
significant reduction of death, MI, stroke, or revascularizationproof that primary PCI was superior to tPA
in STEMI.14,15 Further evidence, from the Senior pami
trial, showed that PCI in elderly patients (age 70 yr)
who presented with STEMI resulted in a significant
reduction in death, MI, or stroke.16 The Primary Coro
nary Angioplasty Trial (pcat) investigators 17 pooled 11
randomized trials of PCI versus fibrinolytic therapy and
found a significantly reduced 30-day mortality rate in
elderly patients (age 70 yr) who underwent PCI, thereby strengthening the evidence favoring PCI in elderly
patients with STEMI.17 The important trials are summarized in Table I. In summary, considerable evidence
supports performing PCI in elderly patients who pre
sent with STEMI, provided that they are eligible for revascularization.

ST-Elevation Myocardial Infarction

Non-ST-Elevation Myocardial Infarction

Elderly patients are at high risk when they present with

ST-elevation myocardial infarction (STEMI), a condition that often accounts for morbidity and death.
Reasons for the high risk include atypical presentation,
delays in seeking medical care, health management by
noncardiologists, and, frequently, admission to hospitals
that have no catheterization facility.7,8 Elderly patients
have been selectively excluded from ACS and revascularization trials because of potentially high mortality
rates. Therefore, evidence has been extrapolated from
studies of younger patients, which precludes extending
the study findings to the population that experiences
the most morbidity and death from ACS.7-9
Primary Angioplasty in Myocardial Infarction-I
(pami-i) is one of the earlier studies that compared primary PCI to f ibrinolytic therapy with tissue plasminogen activator (tPA) in patients with STEMI.10 A
subgroup analysis of this trial showed a trend toward
fewer in-hospital deaths and a significant reduction in
death or recurrent myocardial infarction (MI) in patients aged 65 years who underwent PCI.11 Despite an

There has been considerable debate about the optimal

therapy for elderly patients who present with unstable angina or non-ST-elevation myocardial infarction
(NSTEMI). Opinion is divided between conservative
medical therapy and early-invasive treatment because
some earlier studies showed either no significant difference between the 2 treatment approaches or an increased risk with invasive treatment (PCI). However,
caution must be exercised when interpreting the outcomes of these trials, because they were conducted
before stenting became commonplace and before glycoprotein IIb/IIIa inhibitors were available.
The Thrombolysis in Myocardial Infarction (TIMI)
IIIB trial 18 is one of the earliest studies to have compared early-invasive treatment (routine cardiac catheterization within 48 hours of ACS presentation) with
conservative medical management in patients with unstable angina or NSTEMI. In a subgroup analysis of
this trial, patients aged 65 years or older experienced
a significant reduction in death or MI after early-invasive treatment.18 However, this trial was also con-

Texas Heart Institute Journal

Benefits of PCI in Elderly Patients

399

TABLE I. Trials Supporting PCI in Elderly Patients with STEMI*

Trial
Name
Trial Details

No.
Patients

No. Elderly
Patients

Outcome of Interest

pami-i10

Fibrinolysis (tPA)
395
107 (65 yr)
versus PTCA

Significant reduction in in-hospital

death and death or MI in PTCA group

gusto-iib12

Fibrinolysis
1,138
232 (70 yr)
versus PTCA

33% RRR in 30-d death, nonfatal

MI, or nonfatal stroke in PTCA group

danami-213
Fibrinolysis
1,572

versus transfer

to hospital with

PCI facility

pcat17
(Meta-
analysis)

Exact number
unavailable, but
subgroup analysis
performed on
patients aged >63 yr

Fibrinolysis
2,725
1,457 (70 yr)
versus PTCA

Significant reduction in death, MI,

or disabling stroke at 30-d followup in PCI group

40% RRR in death or reinfarction

at 6 mo in PTCA group

DANAMI = Danish Multicenter Randomized Study on Fibrinolytic Therapy versus Acute Coronary Angioplasty in Acute Myocardial Infarction; GUSTO = Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndrome; MI = myocardial infarc
tion; PAMI = Primary Angioplasty in Myocardial Infarction; PCAT = Percutaneous Coronary Angioplasty Trial; PCI = percutaneous
coronary intervention; PTCA = percutaneous transluminal coronary angioplasty; RRR = relative risk reduction; STEMI = ST-elevation
myocardial infarction; tPA = tissue plasminogen activator
*The inclusion criterion in each trial was ST-elevation myocardial infarction.

ducted in the pre-stent period. The Fragmin and Fast

Revascularization during Instability in Coronary Artery Disease (frisc ii) trial,19 a randomized study of
invasive versus conservative approaches in NSTEMI
patients, was the first to show a significantly reduced
rate of death or MI in the invasive arm of the study. A
subgroup analysis of this trial showed that elderly patients (age 65 yr) had a greater relative and absolute
risk reduction in death or MI in comparison with the
younger patients.20
The Treat Angina with Aggrastat and Determine Cost
of Therapy with an Invasive or Conservative Strategy
(tactics-timi 18) investigators21 compared early-invasive
and conservative approaches in patients with NSTEMI
and concluded that there was a significant reduction in
the composite endpoint of death, MI, and rehospitalization in the invasive arm of the study. In a subgroup
analysis of this trial,22 elderly patients (age 65 yr) had
greater absolute and relative risk reductions in death or
MI at 30-day follow-up. This trial also showed an increasing benefit of an early-invasive approach with advancing age. Although a later trial23 that compared early
versus routine invasive care in patients with NSTEMI
found no significant difference in the outcome between
the 2 approaches, a nonsignificant trend in the elderly subgroup (age 65 yr) favored early invasive care.
This same trend was confirmed in some observational studies in the community population.24 Even though
in-hospital mortality rates were higher among elderly patients, the National Cardiovascular Data Registry for outcomes after PCI showed an overall temporal
improvement in the adjusted in-hospital mortality rate
400

Benefits of PCI in Elderly Patients

after PCI. This finding was more significant in the oldest subgroup of patients.25
In summary, elderly patients with NSTEMI seem
to benefit from an early-invasive approach, but careful
selection of patients on the basis of physicians clinical judgment is necessary to preserve this benefit. Advanced age alone should not preclude PCI in patients
who are otherwise eligible for the procedure.
Cardiogenic Shock

There is conflicting evidence regarding the early-invasive approach in elderly patients who present in cardiogenic shock. The shock trial,26 which examined the
usefulness of early revascularization therapy in patients
with cardiogenic shock, found a significantly reduced
mortality rate in the invasive arm of the study. However, this benefit was seen only in patients younger than
75 years; patients who were 75 or older had worse outcomes after the early-invasive approach. The difference
was attributed to small numbers of elderly patients in
the study and inequalities in the baseline characteristics of those patients in the invasive arm of the study.26
On the other hand, another registry of patients who underwent PCI for cardiogenic shock showed a marked
survival benefit in patients 75 or older who received
emergency revascularization.27 Other studies 28,29 have
shown a significant benefit of emergency revascularization in terms of decreased mortality rates in carefully selected elderly patients with cardiogenic shock. In
summary, there appears to be a definite benefit from
early revascularization in carefully selected elderly patients who present with cardiogenic shock.
Volume 38, Number 4, 2011

Elective Percutaneous Coronary Intervention

Elective PCI has been studied in a randomized controlled trial that was dedicated to elderly patients. The
Trial of Invasive versus Medical Therapy in Elderly
Patients with Chronic Symptomatic Coronary Artery
Disease (time) trial30 compared PCI with optimal medical therapy in elderly patients (age 75 yr) who had
chronic symptomatic CAD (angina). After a follow-up
period of 6 months, the investigators concluded that patients in the PCI arm of the study had improvements
in angina and quality of life and had significant reductions in major adverse cardiac events, primarily due to
a decreased need for recurrent admissions with ACS.
However, at 1-year follow-up, there was no significant
difference in symptoms (angina), quality of life, or
death between the 2 treatment groups.31 Upon 4-year
follow-up, long-term survival was similar between the
invasive-treatment and medical-therapy groups, but
there was still a significant reduction in major adverse
cardiac events among patients in the invasive arm of the
studyagain, due to fewer rehospitalizations for ACS.32
The benefits of both approaches were maintained in
regard to angina relief and improved quality of life.
Also, regardless of whether patients had undergone revascularization initially or only after drug therapy had

failed, their survival rates were better if revascularization

had been performed within the 1st year. Hence, even
though this was a relatively small study, it shows that elderly patients should undergo revascularization regardless of their age, if they are eligible for the procedure
and are symptomatic despite optimal medical therapy.32
Concomitant Pharmacologic Treatment

There is a paucity of evidence to support the use of concomitant pharmacologic therapies in elderly patients
during the periprocedural period. Most evidence pertains to aspirin use in elderly patients with STEMI,
unstable angina, and NSTEMI.33 The Clopidogrel in
Unstable Angina to Prevent Recurrent Events (cure)
trial34 and the pci-cure trial35 both showed that the
use of clopidogrel and aspirin in elderly patients with
unstable angina or NSTEMI decreased the composite
endpoint of death, nonfatal MI, or recurrent revascularization in comparison with placebo, thus supporting the use of clopidogrel in this population. The use of
glycoprotein IIb/IIIa inhibitors in elderly patients who
undergo PCI is controversial, especially because of the
increased risk of major bleeding episodes. However, the
Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (pursuit)

TABLE II. Complication Rate after PCI in Elderly Patients

Trial
Study
No.
No.
Name
Eligibility
Pts.
Elderly Pts.

No. Pts. in
PCI Arm or
Early-Invasive
Therapy

Procedural
Complications

pami-i10
STEMI
395
150
195
(Subgroup
Analysis)

Recurrent ischemia, 19.2%;

Stroke, 1.8%;
Intracranial hemorrhage, 1%;
Vascular repair, 2%

STEMI
1,138
638
565
gusto-iib12

Recurrent ischemia, 5.5%;

Stroke, 1.1%

danami-213
STEMI
1,572 NA
790

Recurrent ischemia, 1.6%;

Stroke, 1.1%

pcat17
STEMI
2,725
1,457
1,348
(Meta-
analysis)

Recurrent ischemia, 2.5%;

Stroke, 0.2%;
Intracranial hemorrhage, 0.07%

frisc ii20 NSTEMI/UA

2,457
1,281
1,170

Stroke, 0.2%;
Major bleeding episodes, 1.6%;
Thrombocytopenia, 0.1%

tactics-
NSTEMI/UA
2,220
962
1,114
timi 18 22

Major bleeding, 9%;

Stroke, 0.3%

ictus23 NSTEMI
1,200
529
604

Major bleeding including

intracranial hemorrhage, 3.1%

DANAMI = Danish Multicenter Randomized Study on Fibrinolytic Therapy versus Acute Coronary Angioplasty in Acute Myocardial Infarction; FRISC = Fragmin and Fast Revascularization during Instability in Coronary Artery Disease; GUSTO = Global Use of Strategies to
Open Occluded Coronary Arteries in Acute Coronary Syndrome; ICTUS = Invasive versus Conservative Treatment in Unstable Coronary
Syndromes; NA = not available; NSTEMI = non-ST-elevation myocardial infarction; PAMI = Primary Angioplasty in Myocardial Infarction;
PCAT = Percutaneous Coronary Angioplasty Trial; PCI = percutaneous coronary intervention; Pts = patients; STEMI = ST-elevation
myocardial infarction; TACTICS-TIMI = Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative
Strategy-Thrombolysis in Myocardial Infarction; UA = unstable angina

Texas Heart Institute Journal

Benefits of PCI in Elderly Patients

401

investigators 36 concluded that, when compared with

younger patients, patients 65 years had a trend toward
benefit in terms of death and MI, thus supporting the
use of glycoprotein IIb/IIIa inhibitors in the older patients.

7.
8.

Complications of Percutaneous
Coronary Intervention in the Elderly
Advanced age is a universal predictor of death in most
cardiovascular diseases and cardiac procedures, including PCI. Age is an independent predictor of death after
PCI.37 The presence of significant comorbidities such as
renal insufficiency, multiorgan dysfunction, and extensive vascular disease may explain the increased mortality rates in elderly patients. Another severe complication
after PCI is bleeding (including intracranial hemorrhage), and age is an independent predictor of major
bleeding after PCI.38 Table II summarizes some important complications that have been noted in prominent
clinical trials.
Conclusion

Elderly persons are a rapidly growing segment of the

U.S. population and can pose a therapeutic challenge
because of specific physiologic and anatomic problems.
Elderly patients are typically treated less aggressively
than are younger patients, due partly to the increased
risk of adverse events and partly to a lack of standard
management guidelines. Older patients have been excluded from large randomized trials due to comorbidities and age, rendering it impossible to decide upon an
optimal approach in most clinical situations. However,
on the basis of current evidence, the decision to perform
PCI should not be based on chronological age alone,
but rather on each patients general eligibility for revascularization and the clinical circumstances as a whole.

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