National life-expectancy is steadily rising with the number of those aged 85 years or over doubling from 1985 to 2010,1 and ever more elderly patients presenting to cardiology. Age is a potent risk factor for mortality after acute coronary syndrome (ACS),2 and older patients with angina present with more severe symptoms and prognostically significant coronary anatomy.3 Age has a very powerful influence on risk stratification tools such as GRACE (Global Registry of Acute Coronary Events), and National Institute for Health and Care Excellence (NICE) guidance supports early invasive investigation and management for high-scoring patients.4 Diagnostic coronary angiography (DCA) is crucial to assessing the cross-spectrum of coronary disease presentation. Despite this, elderly patients are less likely to be treated in accordance with best practice after presenting with ACS,5,6 the so-called ‘risk paradox’. Concern about the safety and efficacy of DCA and percutaneous coronary intervention (PCI) in the more elderly population seems to underpin this behaviour.
There is in fact a wealth of data to indicate that DCA in the elderly has acceptable complication rates,7 and that revascularisation, surgical or by PCI, offers significant benefit.5 The study by Walsh and Hargreaves (see page 37) is welcome in further describing the fallacies of current practice, which fall short of best practice.6
The study
The research is presented as a retrospective case-control study in the modern era of coronary intervention, and gives some insight into current practice. Data from 100 randomly selected patients aged over 80 years and a control group aged below 70 years were taken from a district general hospital (DGH) DCA database. This method of patient selection is perhaps the major weakness of the study. There will inevitably have been a high degree of case selection – particularly of older patients – with those put forward deemed appropriate for DCA (and by implication also considered ‘reasonable’ candidates for revascularisation). The low rate of selection of elderly patients for DCA is confirmed, with only 4% of the overall 17,325 patients in the database aged over 80, despite a much higher prevalence of coronary artery disease (CAD) in this age group.
The investigators chose to explore the difference between the preferred intervention (immediately after catheterisation) and the treatment the patient ultimately received; medical therapy, PCI or coronary artery bypass graft (CABG). The preferred treatment would be decided by the cardiologist performing the diagnostic angiogram and would be weighted more heavily by the coronary anatomy, while the final treatment would take more account of the complete clinical picture. The study design is very similar to that of Elder et al.,3 from the cardiology dark ages of 1991, and thus provides an interesting comparison between the diagnostic and revascularisation strategies of an earlier era and our own. The value of this study is as an observation of practice and comparison with a previous age of cardiology.
As might be expected, a higher number from the elderly cohort were initially recommended for CABG (27 vs. 11 from the control group). An interesting observation is the high rate of later ‘conversion’ of mode of revascularisation in the elderly group; of the 27 patients who were initially put forward for surgery only nine eventually received an operation. In comparison, 10 out of 11 in the control group went on to have surgery. This would confirm the usual supposition that the elderly population have not only a higher predominance of surgical disease, but also comorbidities that produce an unfavourable operative risk, sufficient to dissuade many cardiac surgeons in the modern era of outcomes disclosure.
In terms of the diagnostic angiogram, this study showed no significant difference in complication rates between the two age groups, but the sample sizes were far too small to be able to state this with any confidence, given the very low rate of complications with DCA in modern practice.
It is now well-established that age alone should not have a role in determining who undergoes invasive cardiological management. Frailty assessment, a technique still in evolution, is a more important arbiter in deciding who enters the catheterisation lab8-10
Conflict of interest
None declared.
Editors’ note
See also the study by Walsh and Hargreaves (doi: 10.5837/bjc.2014.003) on page 37 of this issue.
References
1. Office for National Statistics. Topic guide to: older people. Available from: http://www.statistics.gov.uk/hub/population/ageing/older-people/index.html
2. Fox KA, Dabbous OH, Goldberg RJ et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ 2006;333:1091. http://dx.doi.org/10.1136/bmj.38985.646481.55
3. Elder AT, Shaw TR, Turnbull CM, Starkey IR. Elderly and younger patients selected to undergo coronary angiography. BMJ 1991;303:950–3. http://dx.doi.org/10.1136/bmj.303.6808.950
4. Cooper A, Calvert N, Skinner J et al. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London: National Clinical Guideline Centre for Acute and Chronic Conditions, 2010. Available from: http://www.nice.org.uk/nicemedia/live/12947/47931/47931.pdf
5. Devlin G, Gore JM, Elliott J et al. Management and 6-month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: The Global Registry of Acute Coronary Events. Eur Heart J 2008;29:1275–82. http://dx.doi.org/10.1093/eurheartj/ehn124
6. Avezum A, Makdisse M, Spencer R et al. Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE). Am Heart J 2005;149:67–73. http://dx.doi.org/10.1016/j.ahj.2004.06.003
7. Niebauer J, Sixt S, Zhang F et al. Contemporary outcome of cardiac catheterizations in 1805 consecutive octogenarians. Int J Cardiol 2004;93:225–30. http://dx.doi.org/10.1016/S0167-5273(03)00216-X
8. Afilalo J, Karunananthan S, Eisenberg MJ, Alexander KP, Bergman H. Role of frailty in patients with cardiovascular disease. Am J Cardiol 2009;103:1616–21. http://dx.doi.org/10.1016/j.amjcard.2009.01.375
9. Rockwood J, Song X, MacKnight C et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489–95. http://dx.doi.org/10.1503/cmaj.050051
10. Klein LW, Arrieta-Garcia C. Is patient frailty the unmeasured confounder that connects subacute stent thrombosis with increased periprocedural bleeding and increased mortality? J Am Coll Cardiol 2012;59:1760–2. http://dx.doi.org/10.1016/j.jacc.2012.01.042
