01 Sep 2007

Challenges in percutaneous revascularisation in the elderly, ACS

Antoine Lafont

Topics: Acute Coronary Syndromes (ACS)
Session number: 169000
Session title: Challenges in percutaneous revascularisation in the elderly Symposium
Authors: Lafont, Antoine (France)

This session gave us an outstanding outline of our everyday practice in a growing population with increasing challenges. Basically, the risk of non intervention in this population is higher than the high risk of complications related to the complexity of the lesions, comorbidity and increased bleeding.

Dr Neumann discussed the predictors of risk by evaluating the procedure, the safety and the efficacy. Using bare metal stents or drug eluting stents, parameters are similar in various studies: age, diabetes, vessel size, stent length, and left ventricular ejection fraction.

Interestingly the study of Airoldi (Circulation 2007) with an 18 month follow-up did not show any relationship between clopidogrel interruption after 6 months and major adverse events. He insisted on the value of the Syntax score in predicting adverse outcvome in this population after revascularisation.

M. Pfisterer evaluated the limits in revascularisation, facing comorbidities and diffuse lesions through 2 major studies, APPROACH and TIME.
The medical treatment is the worst option in both, TIME compared to revascularisation. PCI is fast, skips general anaesthesia, and reduces hospital stay. However, he would limit indications for patients with mild symptoms, high comorbidity, and very diffuse disease without culprit lesion.

Finally, drug eluting stents should bring a higher benefit in this high risk population.

D. Dudek evaluated the revascularisation options during acute STEMI. In the EUROTRANSFER trial, bleeding is increased in this population. In the PIHRATE trial the myocardial blush grade 3 (MBG 3) decreases even after a successful revascularisation with age (74 to 56%). There is more thrombectomy failure, distal embolisation, and no reflow. However, PCI avoids stroke compared to thrombolysis (PCAT2). In senior PAMI, death is reduced by PCI compared to lytics, except for the very old population. From ACUITY, bivalirudine appears optimal by reducing bleeding compared to GP2B3A.

A. Timmis evaluates the procedural dilemma. He said that common sense dictates a radial approach if possible, short procedures, DES, avoiding direct stenting, use of DES, prevention of renal failure.

F. Schiele, Besançon, FR advocates secondary prevention in this population, usually under-treated. Common sense dictates the use of simple hygienic measures, ie, stop smoking, exercise, and standard medication: aspirin at low dose, clopidogrel if necessary, betablockers, statins if needed, and ACE inhibitors.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.