09 Jun PCI May Be Underutilized in Elderly Patients With Acute Coronary Syndrome
MedicalResearch Interview with:
Mauro Di Bari, MD, PhD
Associate Professor of Medicine – Geriatrics
Director, School of Geriatrics
Vice-president, School of Physiotherapy
University of Florence and Azienda Ospedaliero-Universitaria Careggi
MedicalResearch: What are the main findings of the study?
Professor Di Bari: This study is based on the AMI-Florence 2 registry, which recorded all acute coronary syndromes (ACS) occurring in one year in the metropolitan area of Florence, Italy. This area has one of the top prevalence figures in the country for application of percutaneous coronary intervention (PCI) to treat ACS, at least in cases with ST-segment elevation myocardial infarction (STEMI). Nevertheless, in our study the procedure turned out to be largely underused in older, complex patients, who mostly had NSTEMI: the greater the background risk (as expressed by the Silver Code, a simple, validated prognostic tool based of administrative data), the lower the chances for application of PCI, independent of possible contraindications to PCI, such as anaemia or renal insufficiency.
At the same time, the long-term survival advantage offered by PCI increased with increasing background risk: when comparing patients receiving and not receiving PCI across strata identified on the basis of the Silver Code, one-year survival was only marginally greater in patients treated with PCI when their Silver Code score suggested low background risk, whereas the mortality gradient increased progressively along with Silver Code score, to reach its maximum in patients with the greatest values of Silver Code score. Within the limits of an observational study, cardiac and non-cardiac comorbidities, contraindications to PCI, clinical characteristics of the ACS and hospital of admission could not justify these findings.
MedicalResearch: Were any of the findings unexpected?
Professor Di Bari: That many effective treatments, including invasive coronary reperfusion, are poorly applied in older patients is not a new finding. On the other hand, we were impressed by the fact that an increasing background risk was at the same time associated with progressively greater underuse of PCI and its increasing effectiveness, represented by long-term survival. The more complex and severely ill an older ACS patient is, the greater the benefit he/she can get from PCI, yet the lower the chances she/he is treated: a disturbing paradox! These findings suggest that abstaining from such an aggressive and expensive, but definitively effective, therapy as PCI in the setting of ACS is often the consequence of an unjustifiable therapeutic inertia towards oldest patients, more than a reasonable, clinically appropriate application of the primum non nocere principle.
MedicalResearch: What should clinicians and patients take away from your report?
Professor Di Bari: Cardiologists should avoid excessive restrictions in the application of PCI in older ACS patients, because this is clinically not justifiable and might be responsible for undue mortality. Sometimes it is patients themselves that refuse to undergo invasive procedures because of fear of possible side effects: although this is an age-associated risk, our data suggests that the net benefit of PCI outweighs its possible drawbacks, possibly more and more with advancing age and clinical severity.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Professor Di Bari: This was an observational study and not a randomized trial, therefore residual confounding cannot be excluded. To confirm our findings, new, better designed randomized studies should be conducted: unlike most previous trials, these study should selectively enrol frail older patients, mostly with NSTEMI, similar to those seen in clinical practice, to definitively ascertain whether PCI can be effectively and safely applied even in such clinically challenging individuals.
Mauro Di Bari, Daniela Balzi, Stefania Fracchia, Alessandro Barchielli, Francesco Orso, Andrea Sori, Simona Spini, Nazario Carrabba, Giovanni M Santoro, Gian Franco Gensini, Niccolò Marchionni, For the Acute Myocardial Infarction in Florence 2 (AMI Florence-2) Working Group