1. Are we doing enough PCI in the elderly ? Rosie Swallow Dorset Heart Centre Royal Bournemouth Hospital

2. Definition of an elderly patient

3. Prevalence of CHD by age and sex Age, years Percent of Population

4. PCI risk and age JACC 2000;36:723-30

5. Why is PCI different in the elderly? Heterogeneous population Increased risk & benefit less certain Technical Issues: –Multivessel, diffuse disease –Calcification –LMS disease –Worse LV function

6. STEMI: Does PCI improve prognosis ? Limited evidence available TRIANA study (Rev Esp Cardiol 2005:58:341-50) Senior PAMI (TCT 2005) Probably beneficial

7. FRISC IIInvasive Group Noninvasive Death1.9%2.9% Death/MI>6510.5%15.8% 6 months<658.1% Angina>6521%40% 6 months<6523%38% NSTEMI: Does PCI improve prognosis? Beneficial in high risk patients Lancet 1999;354:708-15

8. NEJM 1999;341:625-34 Total Study Population Age > 75 Cardiogenic Shock: Does PCI improve prognosis ? Probably harmful

9. Does PCI improve symptoms ? Trial of Invasive versus Medical therapy in Elderly patients with chronic symptomatic CAD: TIME 305 pts > 75 yrs medical vs. invasive treatment Lancet 2001; 358:951-7

10. Yes

11. Does PCI improve quality of life ? Improvement in QoL at 6 and 12 months in both groups Significant improvement in QoL at 6 months in the invasive arm compared to the medical treatment arm Lancet 2001; 358:951-7 YesPre DES

12. Is PCI cost effective ? TIME Study – cost effectiveness Higher initial costs in invasive group Cost balanced at one year by symptom driven revascularization in non invasive group EHJ 2004;25:2195-2203 Yes

13. Dorset

14. 69% 25% 6%48% 32% 20%

15. Why is Bournemouth different ? Elderly population Wealthy and Healthy Imported population Few ethnic minorities Buoyant heath economy Receptive commissioners New service

16. What we do in Bournemouth to maximise optimal care Correct pathways in place for chronic angina No age limit for PPCI All ACS reviewed by cardiologists with low threshold for angiography and PCI Functional status review Risk / benefit assessment & discussion is essential Elderly patients often accept increased risk for symptom relief

17. Royal Bournemouth Hospital experience Over 75 yr olds April 05 - December 2007 1102 patients > 75 yrs underwent PCI Procedural success rate = 95.4% In hospital mortality= 0.82% (Elective 0.41% & Urgent 1.1%) In hospital mortality in the under 75yrs in the same period was 0.3%.

18. Royal Bournemouth Hospital experience over 85 yr olds April 2005-December 2007 N = 50 Median age 87 (range 85-95) Angina (28%), ACS (70%) & PPCI (2%) 13 rotational atherectomy Complete revascularisation in 58% cases In hospital MACE = 4%

19. How many PCI would this mean? In 2007, 3894 patients >80 underwent PCI in the UK If RBH model is applied, could increase to > 10,000 PCIs per year Can we justify these potential numbers ? Where should we draw the line ?

20. PCI in very elderly patients: Partial revascularization is it an option ? Keep it simple, treat the easiest lesion DES vs. BMS ? BMS Adjunctive pharmacology ? Avoid GPIIbIIIa, stop warfarin How do we reduce complications ? Short procedure, avoid hypotension, low threshold for rotablation, radial access

21. PCI in the elderly: Conclusions There is no doubt that the disease is there The evidence that we have supports PCI in this group PCI does improve quality of life in the elderly which to them is fundamental It is possible to treat this group of patients and it is inevitable with the increasingly aged population that we will do more It is important to risk assess and discuss the potential benefits on a patient specific basis