Transcript Slide 1

Coronary Artery Disease In Elderly
 M. Dehghani
Interventional Cardiologist
Coronary Artery Disease:
 Chronic Stable Angina
 Acute Coronary Syndrome
Plaque rupture/erosion
Platelet adhesion
Platelet activation
Partially occlusive arterial
thrombosis & unstable angina
Microembolization & non-ST elevation MI
Totally occlusive arterial thrombosis & ST elevation MI
l.
Structure of thrombus
following plaque disruption
.
ACS with persistent
ST-segment elevation
Adapted from Michael Davies
CK- MB or Troponin
ACS without persistent
ST-segment elevation
Adapted from Michael Davies
Troponin elevated or not
Patients presenting with acute coronary syndromes in the
community are substantially
 older
 are more often women
 have more comorbidity
than
patients enrolled in randomized studies that are the basis for
care guidelines, and
clinical outcomes for the oldest patients
are generally worse than trial results.
 About 60% of hospital admissions for acute
myocardial infarction (AMI) are in people
older than 65 years, and
 approximately 85% of
deaths due to AMI occur in this group.
With increasing age, the gender composition of patients
presenting with AMI changes:
 from predominantly men in middle age,
 to equal numbers of men and women between the
ages of 75 and 84 years,
 to the majority of patients with AMI being women at
ages over 80 years
Diagnosis
 Chest pain or
 discomfort is the most common complaint in
patients up to the age of 75 years,
but after the age of 80 years, complaints of

diaphoresis increase

chest discomfort decreases .
 Altered mental status
 confusion
 fatigue
become common manifestations of MI in the oldest patients.
Older patients may also present with
sudden pulmonary edema or
neurologic symptoms such as
syncope or
stroke.
The electrocardiogram (ECG) is also more likely to be
nondiagnostic .
 Nonspecific symptoms and
 Nondiagnostic electrocardiographic findings lead to
delays in
diagnosis and
implementation of therapy
 Highlight the importance of rapid laboratory testing
for
circulating markers of myocardial damage.
Approach to the Older
Patient with Coronary
Artery Disease
The best strategy currently appears to be to initiate
 pharmacologic therapy
 assess risk at the time of presentation
 to consider urgent revascularization for older patients at
highest risk
nonurgently for those at intermediate risk
to be guided by
 symptoms and
 evolving clinical status for
those at low risk.
The patient's preferences should be considered in all
scenarios.
Therapeutic Tools
 Anti-ischemic treatment
 Antiplatelet agents
 Anticoagulants
 Revascularization/Reperfusion/Thrombolysis
 Long term treatment
 secondary prevention
 Patients with a limited life span from a concomitant
illness is probably not a candidate for drug therapy.
 On the other hand,
an otherwise healthy elderly individual
should not be denied drug therapy simply
on the basis of age alone .
Elderly patients may need to be started on
lower doses initially and
should be monitored carefully for side effects
While older adults have been underrepresented
in clinical trials,
there are sufficient data that
medical and
revascularization therapies are
effective in older
adults
 Optimization of medical care warrants greater
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emphasis.
Exercise for all,
Weight loss for the overweight
smoking cessation in smokers
Control of hypertension and diabetes
For relief of symptoms—
beta blockers
nitrates
calcium channel blockers
All of the drugs used in younger patients for the control
of anginal symptoms are appropriate for older adults.
However, older adults may experience more side effects,
particularly hypotension from
 nitrates
 calcium channel blockers
 central nervous system effects from beta blockers
For prevention of complications:
 antiplatelet drugs
 lipid lowering
 Pharmacologic treatments must
incorporate age-related adjustments in dosing;
consider altered reflex responses and
drug interactions.
Morbidity and mortality from CAD and CAD treated
 medically or
 with revascularization
increase with age, especially at ages older than
75 years, and there are
No advantages of
revascularization over
optimal medical care for the older patient with
 stable or
 nondisabling CAD or
 who has a satisfactory quality of life.
Medical therapy has become
compares favorably with
revascularization in
randomized trials of
stable CAD patients older than 75 years,
especially women.
The decision whether to continue with
 optimal medical therapy or
 perform revascularization requires the elderly patient's
understanding of the
 strengths and
 weaknesses of each approach and a respect by the
healthcare delivery team of that patient's subsequent
preferences
In contrast to the relatively
low complication rates of revascularization in
randomized trials of highly selected elderly patients,
 morbidity and
 mortality with revascularization in routine clinical
care
in patients older than 75 years
are high
 Revascularization procedures in the elderly are
increasing,
with greater increases in the numbers of
percutaneous coronary intervention (PCI) procedures
than
in coronary artery bypass grafting (CABG).
In randomized trials, patients aged 65 to 80 years have
been reported to have higher

early morbidity and

mortality

Strock
after CABG compared with PCI but greater

angina relief and

fewer repeated procedures
after CABG.
Treatment decisions are often considered separately for
 ST elevation MI (STEMI) and
 Non–ST elevation MI (NSTEMI) and
Unstable Angina
in the older patient analogous to other guidelines.
The Timing of Intervention in Acute Coronary Syndromes
(TIMACS) trial
included patients older than 75 years and found
no difference between
 early and
 delayed invasive strategies in
low- to
intermediate-risk patients (by GRACE score).
 For higher risk patients,
early intervention
reduced composite short-term cardiovascular
endpoints.
Invasive Strategies in STEMI
In elderly patients with acute STEMI,
 primary angioplasty in experienced centers is associated
with improved outcomes compared with
 thrombolytic strategies .
This potential benefit, however, has not been seen in
octogenarians.
For patients older than 80 years, there are limited data.
Recommendations are based on extrapolations from
 younger and
 less sick
populations.
Incremental benefits between therapies are small.
Decisions between
 PCI and
 fibrinolytics or
 neither
in patients older than 75 years should be
individualized
Reperfusion
 Non–age-adjusted guidelines
recommend reperfusion approaches in STEMI
patients without contraindications if they present
within 12 hours of symptom onset.
 PCI and fibrinolytic therapy have similar outcomes
when they are delivered within 3 hours from symptom
onset.
 In elderly patients who present in
shock or are in
a high-risk category or
present later,
PCI can offer better
results
 There is general agreement that eligible STEMI
patients who receive reperfusion therapy (fibrinolytic
therapy or PCI) have a lower risk of death,
but few patients older than 75 years were
enrolled in trials that serve as the basis for this
recommendation.
 In-hospital mortality of patients older than 75 years is
estimated to be fourfold to fivefold higher than in
younger patients.
 For those older than 80 years, 2005 registry data for
primary PCI for STEMI show in-hospital mortality as
16.6%.
Acute procedural success rates are somewhat lower in
older patients and are associated with
 increased bleeding and
 increased risk for contrast-mediated renal
dysfunction.
Cardiac rupture risk with thrombolysis is also increased
in patients
 older than 70 years and
 in women
Thrombolysis or Fibrinolysis
For patients up to the age of 75 years, most trials show
that
 fibrinolytic,
 antiplatelet, and
 antithrombin therapy
is associated with a survival advantage compared with
placebo
that may be similar to or less than that seen in
younger patients..
 Bleeding and
 transfusion rates
are higher in older patients,
especially with improper dosing of
antiplatelet and
antithrombin agents
Early CABG mortality increases from
 below 2% in patients younger than 60 years to
 between 5% and 8% in patients older than 75 years,
 approaching 10% in patients older than 80 years
 Elderly women are at highest risk, in part because of
comorbid conditions.
 For patients older than 90 years, operative mortality
has been reported as 11.8% in the Society of Thoracic
Surgeons database.
 Fibrin-specific agents are also associated with
increased stroke risk due to intracerebral hemorrhage
in those
older than 75 to 80 years.
 Further improvement in the outcome in
patients optimally treated with
 Aspirin
 Clopidogrel / Prasugrel
 Statins
 Ace inhibitors
 Beta blockers
?
DISCHARGE PLANNING
 ASA, clopidogrel
 BB
 ACEI
 BP control
 Lipid management
 DM management
 Smoking cessation
 The increase in absolute risk in the elderly suggests
that the benefit from cholesterol-lowering therapy
should be greater than in younger individuals.
 This point, although not widely appreciated, has
important implications for treating
hypercholesterolemia in the elderly
DISCHARGE PLANNING contd
 Weight management
 Exercise program
 Cardiac rehab
 Pt education
 Influenza vaccine
 Depression screening
 Generally advise against HRT in women
 At least half of PCI procedures and CABG are
performed in patients older than 65 years, with one
third in patients older than 70 years
 Stroke is more common after CABG than after PCI
(1.7% versus 0.2%), and
heart failure and
pulmonary edema
are more common after PCI (4.0%
versus 1.3%).
EARLY INVASIVE PREFERRED
Recurrent angina, angina at rest
Elevated cardiac biomarkers
New ST depression
New HF or MR
High risk noninvasive
Hemodynamic instability
Sustained VT
PCI within 6 mos
Prior CABG
High risk score (TIMI or GRACE)
LVEF <40%
 Death rates were the same with both approaches.
These data were published after the updated 2007
guidelines, which stated that
 an initial conservative strategy (selected invasive)
could be considered but
 favored rapid revascularization for older unstable
angina/NSTEMI patients
NSTEMI
Inferior MI
Revascularization presented an early risk of
 death and
 complications, and
optimized medical therapy carried a chance of later
events
hospitalization and
revascularization,
without a clear advantage of either strategy.
ST elevation MI has a high mortality in the oldest 
patients.
Immediate invasive strategies show the greatest
benefit in higher risk patients.
In analyses of community practice outcomes
of five recommended therapies (early use of
aspirin, beta blockers, heparin, GP IIb/IIIa
inhibitors, and cardiac catheterization), inhospital mortality declined as a function of
the number of guideline-recommended
therapies given in patients aged 75 years and
older, with greater benefit with use of
guideline-recommended therapies in older
than in younger patients.
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Chest pain (variously described, but
classically it is pressure-like)
Shortness of breath
Nausea/Vomiting (especially in inferior MI)
Diaphoresis
Weakness
Syncope
Comparison of
Medical Therapy with
Revascularization
Decisions about medical therapy versus
revascularization, or for PCI versus CABG,
should be based on the role of CAD in the
context of the individual older patient's
overall health, lifestyle, projected life span,
and preferences

For patients at lower or intermediate risk,
treatment choices should be based on
consideration of patient and family
preferences, quality of life issues, end-of-life
preferences, sociocultural differences, and
the experience and capabilities of the site of
care.
All treatment regimens must be adjusted for
renal status and size.


Risks of reperfusion in patients older than 85
years appear to differ from those in younger
patients, supporting individualized clinical
decisions
Acute Coronary Syndrome
UA/NSTEMI 9/00
No ST Elevation
ST Elevation
NSTEMI
Myocardial Infarction
Uns Angina NQMI
Qw MI
A recent randomized comparison of
immediate invasive strategy with next
working day invasive intervention in patients
with NSTEMI using modern antiplatelet
regimens found no difference in peak
troponin levels between the two strategies in
patients older or younger than 75 years.[109]

With special attention to altered dosing for
and sensitivity of older patients and close
observation for adverse effects of intensive
medical and interventional management in
elderly subgroups with acute coronary
syndromes, short-term morbidity can
potentially be further reduced.

In addition to laboratory studies such as
blood glucose or a lipid profile, an
electrocardiogram should be obtained if
medications are altered or if the history or
physical examination have changed

For NSTEMI, the debate centers on early
versus delayed or selective risk-stratified
invasive strategies after antiplatelet and
antithrombin therapy and initiation of beta
blockade and ACE inhibitors or ARBs in the
presence of left ventricular dysfunction
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FOLLOW-UP
Patients with chronic stable angina require
follow-up on a regular basis.
We suggest follow-up every 6 to 12 months
At each visit, a detailed history should be
obtained and physical examination
performed.
In particular, it is important to establish:
A change in physical activity
Any change in the frequency, severity, or
pattern of angina

Tolerance of and compliance with the medical
program

Modification of risk factors

The development of new or worsened
comorbid illnesses


Those at high risk for intracerebral hemorrhage
include:
 patients older than 75 years,
 women
 smaller patients (<65 kg for women and <80
kg for men), and
 those with prior stroke or
systolic blood pressure >160 mm Hg.
Information about elderly patients after
revascularization as part of “routine” clinical
care has emerged from clinical and
administrative databases (Fig. 80-8).

Data on PCI during 2004-2006 found similar inhospital mortality rates
 up to 1% for those up to 70 years of age
 about 2% for 70- to 80-year-olds, and
 3.2% for those older than 80 years
Combined postmarketing registry and trial data
compared
 bare metal stents and paclitaxel drug-eluting
stents in patients older than 70 years.
 Bare metal stents and drug-eluting stents had
similar
death,
MI, and
stent thrombosis rates, although
repeated revascularization was
more common with bare metal
stents..
PCI is associated with a
 slightly less than 1% risk of permanent stroke
or coma, and
CABG is associated with a
 3% to 6% incidence of permanent stroke or
coma in patients
older than 75 years.
The bias against older individuals stems from
illusory concerns regarding life expectancy,
comorbidity, safety of lipid lowering agents, and
cost-benefit analysis of preventive care in older
adults.
 In fact, the absolute risk for CHD increases
dramatically with age in both men and women
(figure 1).
 Thus, the absolute number of persons benefiting
from cholesterol lowering should be greater in
older adults [1,2].

Because CHD morbidity and mortality rates
increase with age, the attributable risk of
high total cholesterol is greater in the elderly
even though the relative risk decreases with
age (ie, a smaller percentage of a larger
number of events results in a larger increase
in absolute risk) (figure 3).

Time course for CHD benefit — The
prevention of CHD in elderly subjects has
been hindered by the perception that LDL
lowering therapy requires many years before
the course of atherosclerosis can be altered.



This concept has been challenged by the
observation that clinical benefits are seen as
early as six months to two years (figure 5), in
many cases before atherosclerosis regression
has occurred [36-38].
In addition, statin therapy can improve
endothelial dysfunction within three days of
initiating therapy
Summary
The decision whether to treat high or highnormal serum cholesterol in an elderly
individual needs to be individualized, being
based upon both chronological and
physiologic age.


The studies described above support the use
of lipid lowering therapy for secondary
prevention in older patients with established
CHD who do not have life-limiting comorbid
disease

On the other hand, over 50 percent of older
individuals will eventually die from
cardiovascular disease and data from the
Cardiovascular Health Study suggest
significant benefit from primary prevention in
patients ages 65 and older

Despite their proven benefit, lipid-lowering
drugs are markedly underutilized in elderly
patients

Dietary modifications — While therapeutic
lifestyle changes involving exercise and diet
are generally the first line of treatment for
dyslipidemias, providers should avoid dietary
restrictions in older patients who are at high
risk of malnutrition.
These include patients with dementia or
physical disabilities that limit their access to
adequate nutrition


SUMMARY AND RECOMMENDATIONS
●Coronary heart disease (CHD) is the most common cause of
death in older patients, and, as in younger patients, dyslipidemia is
associated with an increased risk of CHD. (See 'Cardiovascular
disease in older adults' above.)
●Although the relative risk of hypercholesterolemia is somewhat
lower in older patients, the absolute risk is higher than in younger
patients. (See 'Relative risk versus attributable risk' above.)
●The relative benefit of lipid lowering therapy in older patients is
similar to that in younger patients, and the absolute benefit is
typically greater than in younger patients. Particularly in
secondary prevention, the absolute benefits are large enough that
many older patients with CHD would benefit from lipid-lowering
therapy, and older patients with a reasonable life expectancy may
also benefit in primary prevention. Side effects of lipid lowering
therapy may also be similar in older and younger patients

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Reductions in events with statin therapy can
occur quickly (within weeks to months), and
so even in older patients such therapy can be
expected to reduce events during a patient’s
expected lifespan

Secondary causes of dyslipidemia such as
hypothyroidism, diabetes, nephrotic
syndrome, and drug effects should be
considered, particularly in older patients.

In the immediate postoperative period,
 longer durations of ventilatory support
 greater need for inotropic support and
 intra-aortic balloon placement, and
 greater incidence of atrial fibrillation
 bleeding,
 delirium,
 renal failure,
 perioperative infarction,
 infection are seen in
older patients compared with younger patients


The highest rate of complications is usually
seen in older women and in patients
undergoing emergency procedures.
The length of disability and rehabilitation
after procedures is also usually longer


PCI is attractive in concept, but even drugeluting stents may not confer the benefit of
CABG in older patients with longer
anticipated life spans.
The possibility of disability or prolonged
hospitalization after interventions and
especially surgery must be considered and
accurately conveyed to the patient and family
Death, recurrent angina, or MI may not be
viewed as carrying the same negative impact
as a disabling stroke by many older patients.
For the patient unable to make decisions,
involvement of family members or agents is
key to decisions that reflect the wishes of the
patient.

Current Issues in Revascularization of the
Elderly
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Mortality rates are usually higher in older
women than in men with AMI, as are adverse
outcomes with thrombolytics, fibrinolytics,
and GP IIb/IIIa inhibitors.
Mortality is at least threefold higher in the
patient older than 85 years compared with
the patient younger than 65 years.

Lack of consensus on the best approach for
reperfusion for acute MI in the elderly reflects
the lack of data and the comorbidities and
delayed presentation of older patients as well
as the lack of widespread rapid access to
high-volume PCI facilities and the higher
incidence of serious adverse effects with
pharmacologic reperfusion strategies.
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It is unlikely that randomized trials will
provide the answers to these questions in the
very old patient, and registry data that
include significant numbers of women and
older patients with comorbidities serve an
important role for this group.
These data show that results in the
community setting do not currently achieve
the same results as reported in clinical trials.
Coadministered low-molecular-weight or
unfractionated heparin at excess doses
contributes to the excess bleeding.[3]
 Dosage adjustments for
weight and
estimated renal clearance
may decrease but not eliminate risks of
bleeding in very old patients and in women.
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Antithrombotic Agents
Aspirin (81 to 325 mg/day) reduces mortality
in patients older than 70 years and is
recommended for older patients with acute
coronary syndromes of all types.
Clopidogrel is added to aspirin in patients
 not considered for surgical revascularization
 before PCI, or
 before discharge for medically treated
patients.
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GP IIb/IIIa inhibitors in high-risk non–ST
elevation acute coronary syndromes,
especially if catheterization and PCI are
planned, appear efficacious in patients older
than 70 years, although net benefit may
decline with increasing age.
Bleeding risk including intracerebral
hemorrhage is increased about twofold with
GP IIb/IIIa inhibitors, rising to 7.2% for
eptifibatide in patients older than 80 years.[
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Women are more likely to receive excess GP
IIb/IIIa doses than are men in both clinical
practice and randomized trials, and about
25% of the bleeding risk in women is
attributable to excess dosing.
These data highlight the need for adjustment
of dosing of
antithrombotic and
antiplatelet agents
for estimated renal clearance.
TYPES OF PLAQUES
Fibrous Cap
Media
Lumen
“Vulnerable”
Plaque
Lumen
- T-Lymphocyte
- Macrophage
- Foam cell
- Activated intimal
SMC
Lipid Core
Dr.Sarma@works
“Stable” Plaque
It is clear that this question will not be answered
in clinical trials. The published data suggest that
benefits of invasive strategies relate primarily to
later events and need for subsequent
revascularization, except in older patients with
cardiogenic shock due to left ventricular failure
who have improved long-term survival with
early invasive strategies.[107] There is growing
evidence to support an invasive strategy that
can be “delayed” for a period of hours to days to
allow stabilization, initiation of pharmacologic
therapy, and risk assessment

Current Perspective
Despite increased morbidity and mortality for
older patients with CAD and acute coronary
syndromes compared with younger patients,
risk-adjusted AMI mortality in the United
States has decreased from 1995-2006 in the
Medicare population.[
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In contrast to current trends for increased
rates of cardiac catheterization and
revascularization in lower risk MI patients,
use of early invasive strategies should be
redirected to high-risk patients, who may
have greater benefit
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Post–Myocardial Infarction
Medications
Administration of aspirin, beta blockers, ACE
inhibitors, or ARBs in patients with left
ventricular dysfunction and lipid-lowering
drugs for the post-MI patient is based on
clinical trial data showing benefit in
populations that have included elderly
patients.
With the caveat of adjustment of dosing for
age and renal status, recommendations are
the same as in younger patients (see Chap. 49
and earlier).
In contrast, eplerenone did not show either
cardiovascular mortality or all-cause
mortality benefits for patients older than 65
years with heart failure after MI.[111]
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The addition of clopidogrel to aspirin after
non–ST elevation MI has similar benefits in
patients younger and older than 65 years,
without significant data on patients older
than 75 years.[112]
Considerations that may be unique to the
elderly patient after MI are the use of
antidepressants and hormonal replacement
therapy.
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The feasibility of and improvement with
intensive exercise interventions have been
shown for the elderly, including the frail elderly,
residing in the community as well as in the
nursing home. The Cardiac Rehabilitation in
Advanced Age (CR-AGE) trial compared
hospital-based cardiac rehabilitation with homebased cardiac rehabilitation in cognitively intact
patients from the ages of 46 to 86 years with
recent MI.[

Similar improvement in total work capacity and
health-related quality of life was seen with
home-based rehabilitation and hospital-based
rehabilitation in all age groups without
improvement in the control group. Improvement
was somewhat smaller in the group older than
75 years. Benefits decreased over time after
hospital rehabilitation but were maintained with
home cardiac rehabilitation, and costs were
lower in the home rehabilitation group.
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The high prevalence of hypertension,
diabetes, obesity, and inactivity in the elderly,
including those aged 65 to 75 years, would
suggest that increased efforts to improve diet
and activity levels, smoking cessation,
treatment of hypertension and diabetes, and
optimization of renal function would be of
greater benefit on overall morbidity and
mortality than screening with vascular
imaging studies in the asymptomatic elderly.
Anticipated procedural complication rates
should reflect the age and health status of
the patient, not complication rates from
randomized studies or younger patients.
Recovery times will be prolonged from all
procedures.
Depression should be evaluated.

Coronary Artery Disease
In older patients unable to exercise,
pharmacologic agents such as
 dipyridamole and
 Adenosine
can be used with nuclear scintigraphy to assess
myocardial perfusion at
rest and after
vasodilation;



or agents such as dobutamine can be
combined with
echocardiography or
other imaging techniques to assess
ventricular function at rest and during
increased myocardial demand.


The value of screening for asymptomatic
CAD in the elderly is not known.
The presence of coronary calcifications is
high (Fig. 80-7), and
neither the presence
nor degree of coronary calcification
has correlated with coronary flow
decrease in the older population, and
data are especially limited for
women.
Antiplatelet therapy with clopidogrel (or
prasugrel) has a routine role before PCI but
should not be used in patients considered for
CABG.
 Prasugrel has increased risk of fatal bleeding
events compared with clopidogrel in patients
older than 75 years with acute coronary
syndromes and should not be used in older
patients.
 Early versus delayed eptifibatide before
angiography is not recommended.[

Two randomized trials have attempted to
compare PCI with fibrinolysis in older patients
with STEMI, and both were terminated
prematurely because of inability to meet
recruitment goals: the Senior PAMI[105] and
the recently presented TRIANA trial.[106

Carotid revascularization Role in asymptomatic patients ≥75 years 
has not been established.
Symptomatic patients with 70% to 99% internal carotid artery
stenosis without other risks for short-term mortality
Selected patients with high-risk lesions by operators with low
mortality rates
Carotid endarterectomy is the standard for the lower risk older
patient.
The oldest patients have the worst results with transvascular 
carotid interventions.
Carotid artery stenting with protection devices is an alternative for
the higher surgical risk symptomatic older patient.
Subgroup analyses from primary prevention trials of 
statins, including AFCAPS/TexCAPS, and ASCOT-LLA
found similar relative effects of therapy on clinical
endpoints in younger and older individuals [26-28]. In
JUPITER, a large trial of rosuvastatin in patients with lowto-average LDL-C levels and elevated c-reactive protein
levels, although the relative risk reductions were similar in
older and younger patients, the absolute reduction in the
primary composite cardiovascular endpoint was 0.77
events per 100 patient-years in the 5695 patients ages 70
and older, which was greater than the reduction of 0.52
events per 100 patient-years seen in the 12,107 patients
ages 50 to 69
Approach to the Older Patient with Peripheral Artery Disease 
Treatment of cardiovascular risk factors and supervised walking- 
based exercise programs are first-line therapy.
Antiplatelet therapy with aspirin or clopidogrel is usually 
recommended.
Medications can improve symptoms (cilostazol > pentoxifylline);
cilostazol should not be used in patients with heart failure.
Thorough examinations of the feet should be included in
examinations.
Patients with decreased sensation or at risk for lesions should be 
referred to foot care specialists.
Revascularization options include PCI for iliac
disease, but long-term efficacy requires
surgical approaches at the femoropopliteal
and infrapopliteal level.
Surgical morbidity and mortality increase
with age, and postoperative recovery times
can be prolonged.
All are highest in the setting of surgery for
critical ischemia or limb salvage.


Current Controversies
Current controversies include the following:
optimal pharmacologic therapies for PAD;
role of prostaglandins and angiogenesis
therapy; optimal endovascular techniques;
and role of endovascular procedures versus
surgical procedures.


 Five-year survival rates are above
80% for both procedures
These patients tend to be
 older and to have
 more multivessel disease and
 comorbid conditions than those in
randomized studies, and long-term survival
rates are lower and complication rates are
higher than in randomized trials
An online risk calculator incorporating patient
risk factors and risks for specific surgical
procedures can be accessed at the Society of
Thoracic Surgeons website. The Mayo Clinic
Risk Score for PCI also appears to estimate inhospital mortality risk for CABG.[90]

PCI




Registry data from 2000 found PCI in-hospital
mortality risk of
less than 1% in patients younger than 60
years that
increased to 2% to 5% in patients older than
75 years and to
more than 5% in patients older than 80
years.]
PCI versus CABG 
One initial study of nearly 1700 patients older than 80 
years (two- or three-vessel disease, excluding left
main) found better in-hospital mortality and shortterm survival for PCI versus CABG (3% versus 6%),[91]
but survival was better after CABG for those surviving
6 months. The larger New York State database of
more diverse patients older than 80 years (n = 5550)
with multivessel disease (excluding left main) found
risk-adjusted mortality and need for revascularization
lower in patients treated with CABG (on-pump)
compared with those who underwent PCI (bare metal
stents).[
A registry-based comparison of drug-eluting
stents and CABG for multivessel disease
(excluding left main, prior CABG, or recent
MI) found that CABG had lower adjusted
death rates and MI than drug-eluting stents,
with clear advantages of CABG in those older
than 80 years.[94]
However, death or MI occurred in 16% to 17%
of patients older than 80 years at 18-month
follow-up


. Randomized trials have reported both
improved cognitive outcomes and no
difference in cognitive outcomes of off-pump
versus on-pump CABG.[96]

. Postoperative cognitive impairment in older
patients detected with neuropsychological
testing has been estimated at 25% to 50%
after CABGPre-revascularization
considerations in the older patients should
address cognition and the potential need for
in-home assistance after the procedure or
extended care hospitalization. Postprocedure
considerations should also include evaluation
for depression (see later).

A pivotal randomized study TIME[97]
compared invasive (PCI or CABG) versus
optimized medical therapy for CAD patients
older than 75 years with angina refractory to
therapy with at least two antianginal drugs
(mean 2.5 ? 0.7) (see Table 80-e3 on website).
Initial 6-month analyses favored
revascularization, but the advantage was not
present at 1 year.

Similarly, comparisons of revascularization
with medical therapy in diabetics, including
women and the elderly, found no significant
difference in outcomes between the
approaches..



Prompt revascularization decreased major
cardiovascular events in CABG-treated
patients compared with the medically treated
but not in prompt PCI patients compared
with medical treatment.
Evolving data also suggest that PCI may not
have fewer neurocognitive consequences
Clinical Perspective
Age alone should not be the only criterion in
considering revascularization procedures.
There is a clear role for individualized risk
assessment and respect for the patient's
preference in the decision-making process.
Short-term and long-term benefit should be
considered in the context of anticipated life
span and quality of life of the patient.


The older old patient with AMI presenting for
care in the community differs from both
middle-aged and younger elderly patients
and is also substantially different from highly
selected patients older than 65 years enrolled
in randomized clinical trials.

Current issues include the following: appropriate
selection criteria for specific therapies for
octogenarians and nonagenarians; modifiable
risk factors for revascularization mortality and
morbidity in older patients; age-adjusted PCI
and CABG protocol regimens; role of transradial
approaches for PCI; benefits of on-pump versus
off-pump CABG surgery (see Chap. 84);
prevention of cognitive decline after
revascularization procedures; and comparisons
between modern medical therapy and
revascularization.

Patients enrolled in trials for treatment of
AMI are generally younger, are more often
male, and have less renal failure and less
heart failure than patients in either the
Medicare database or clinical registries.]

Depression affects 10% of community-dwelling
older people (see Chap. 91). The prevalence of
depression in patients after MI is estimated at
20% to 30% for major depression[113] and up to
50% for potentially significant symptoms of
depression.[114]
Studies show associations between depression
and low perceived social support and increased
cardiac morbidity and mortality in post-MI
patients and in patients undergoing CABG


Individual trials of counseling interventions in patients 
with depression have not shown cardiac benefit, but
meta-analyses suggest benefit. Trials of selective
serotonin reuptake inhibitor (SSRI) antidepressant
therapy in patients with depression after acute
coronary syndromes or MI suggest benefits of SSRI
use on either cardiac events and mortality (perhaps
due to antiplatelet properties) or quality of life and
overall function, especially in patients with a prior
history of depression. Screening for depression can
take the form of a simple two-question test followed
by additional evaluation for patients with answers
suggesting the presence of depression.
Alternatively, the nine-item self-report Patient Health 
Questionnaire screening instrument can be used in
literate patients, or the geriatric depression screen for
older patients can be administered.[115] Increasing use
of SSRI and mixed-mechanism antidepressants has
led to recognition of hyponatremia with SSRIs and
that SSRI antiplatelet effects can increase the risk of
bleeding in combination with warfarin, lowmolecular-weight heparin, or aspirin and in patients
with hereditary platelet defects.[116] The firstgeneration SSRI fluoxetine confers increased risk of
syncope in elderly patients.
Randomized trials comparing administration of
hormone replacement therapy in the form of
combined estrogen and progesterone or
estrogen alone have shown overall lack of
cardiovascular morbidity or mortality benefit
and potential harm for both secondary and
primary prevention in postmenopausal women
(see Chap. 81).[117] Similar to estrogen, the
selective estrogen modulator raloxifene lowered
LDL-cholesterol and increased HDL-cholesterol
but did not decrease coronary event rates and
increased stroke rates and thromboembolism.

A comparison of raloxifene to tamoxifen for
prevention of breast cancer in women found
equivalent efficacy in invasive breast cancer
reduction, equivalent risks for ischemic
disease and stroke, and lower risk of
thromboembolic events with raloxifene.[119]
Neither estrogen nor estrogen plus
progesterone, raloxifene, or tamoxifen can be
recommended for cardiovascular disease
prevention or treatment.
