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104]

Original Article

Primary Percutaneous Coronary Intervention in

Elderly (Age ≥75 Years) Indian Population – Immediate‑ and
Short‑Term Results
Ankur Gautam, Jamal Yusuf, Vimal Mehta, Saibal Mukhopadhyay
Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India

Abstract
Background: Primary percutaneous coronary intervention (PCI) is the best reperfusion strategy for patients presenting with ST‑segment
elevation myocardial infarction (STEMI). Limited data exist on outcomes of primary PCI in elderly patients due to frequent exclusions
of this cohort from the trials. The aim of the present study was to evaluate the acute and short‑term outcomes of primary PCI in STEMI
patients aged ≥75 years. Material and Methods: A total of 50 elderly patients undergoing primary PCI were prospectively enrolled between
December 2017 and May 2019. Inhospital and 6‑month outcomes of patients were recorded and analyzed. Results: The mean age of the
patients was 78.32 ± 3.1 years (range = 75–90 years), and 38.0% were women. Almost half of the patients had triple‑vessel disease, and
the most common infarct‑related artery was left anterior descending artery. Angiographic success was achieved in 78% of the patients, and
inhospital mortality rate was 8%. Complete heart block at presentation, Killip Class III, delayed presentation (>6 h), moderate‑to‑severe
left ventricular systolic dysfunction, slow‑flow or no‑reflow phenomenon, diabetes, and nonresolution of ST segment were major predictors
of inhospital mortality. Conclusion: We demonstrate the favorable immediate‑ and short‑term outcomes of primary PCI in elderly patients
aged ≥75 years presenting with STEMI and conclude that it can be safely and successfully performed in this population with acceptable
rate of complications.

Keywords: Angiographic success, elderly, inhospital mortality, primary percutaneous coronary intervention, ST‑segment elevation
myocardial infarction

Introduction therapies, they are frequently excluded from clinical trials

Age is a major cardiovascular risk factor, and coronary
artery disease (CAD) is the most common cause of death in
the elderly.[1] CAD and its associated acute events such as
ST‑segment elevation myocardial infarction (STEMI) are very
frequent in the aged population and cause significant morbidity
and mortality.[2,3] Worse outcome is influenced not only by
more complex comorbidities but also by the extensive CAD,
advanced coronary lesions, significant coronary calcification,
tortuous vascular anatomy, and suboptimal angiographic
results.[4] In addition, elderly patients are more likely to suffer
from complications following revascularization procedures.[5]
Moreover, their presentations are frequently atypical, leading
to incomplete diagnosis and delayed presentation.[6] Even
owing to higher morbidity and mortality associated with the
primary percutaneous coronary intervention (PCI).
Primary PCI is currently the treatment of choice and the best
reperfusion strategy for patients presenting with STEMI.[7,8]
Address for correspondence: Dr. Jamal Yusuf,
Department of Cardiology, First Floor, Academic Block, Govind Ballabh Pant
Institute of Postgraduate Medical Education and Research (GIPMER),
New Delhi, India.
E‑mail: jamalyusuf72@yahoo.com
Subnitted: 07‑May‑2020 Revised: 11-Jun-2020
Accepted: 01-Jul-2020 Published: 27-Aug-2020

though elderly patients constitute a major high‑risk population

of patients with STEMI who might benefit from more invasive This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
Access this article online is given and the new creations are licensed under the identical terms.
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How to cite this article: Gautam A, Yusuf J, Mehta V, Mukhopadhyay S.

DOI: Primary percutaneous coronary intervention in elderly (age ≥75 years)
10.4103/jpcs.jpcs_43_20 Indian population – Immediate‑ and short‑term results. J Pract Cardiovasc
Sci 2020;6:153-61.

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Gautam, et al.: Primary angioplasty in elderly Indian population
Although the effectiveness and safety of primary PCI among
patients (<75 years old) has been proven through randomized
trials, current guidelines showed no specific recommendations
for older STEMI patients (≥75 years) with regard to the
reperfusion strategy because of the lack of evidence.[9] Given
the limited data on outcomes of primary PCI in elderly patients,
we planned to evaluate the inhospital acute and short‑term
outcomes of primary PCI in patients aged ≥75 years.
Materials and Methods
Study subjects
Our study is an observational prospective study, carried out
over a period of 18 months from December 2017 to May
2019. The study protocol was approved by the local ethics
committee (ID NO. 17/IEC/2017/216), and each participant
provided written informed consent. A total of 50 patients
with STEMI aged ≥75 years were prospectively enrolled.
STEMI was defined as patients presenting with symptoms of
myocardial ischemia accompanied by a persistent elevation
of the ST segment at J point of ≥2 mm (0.2 millivolts [mV])
in men or ≥1.5 mm (0.15 mV) in women in leads V2–V3
or ≥1 mm (0.1 mV) in two other contiguous chest leads or
limb leads or new left bundle branch block on presenting
electrocardiogram (ECG).[10,11]
Inclusion criteria
Patients with chest pain accompanied by ST‑segment elevation
presenting within the first 12 h after the symptom onset with
age ≥75 years were included.
Exclusion criteria
Patients with killip class- IV, cardiogenic shock, left main
coronary artery involvement, mechanical complications of
myocardial infarction (MI) requiring surgical intervention,
history of coronary artery bypass grafting, rheumatic heart
disease, any malignancy, life expectancy < 1 year and inability
to receive dual antiplatelet therapy were excluded from the
study.
Aims and objectives
The aim of the study was to evaluate the inhospital acute
and short‑term outcomes of primary PCI in STEMI patients
aged ≥75 years. The objectives of the study were the clinical
outcomes in terms of the composite of death from any cause,
MI, target vessel revascularization (TVR), and stroke at the
time of index hospitalization as well as at 6‑month follow‑up
and correlate it with various demographic, clinical, and
angiographic variables of the participants.
Methods
All patients had undergone detailed history and clinical
examination. Details of the history, examination, investigations,
demographic characteristics, Killip class, and time from
symptom onset to PCI were recorded on a predesigned
pro forma after due consent. Baseline routine blood
investigations – complete blood count, kidney function
test, random blood sugar, and viral markers – were done
154 Journal of the Practice of Cardiovascular Sciences ¦ Volume 6 ¦ Issue 2 ¦ May-August 2020
(2 ml of blood). Loading dose of 325 mg of aspirin and 600
mg of clopidogrel was given in the emergency room. A 12‑lead
ECG (25 mm/s paper speed) was recorded at admission and
immediately after primary PCI of each patient. ST‑segment
resolution was measured manually in infarct‑related leads.
ST‑segment resolution was defined as resolution of the initial
sum of ST‑segment elevation ≥70%.
Angiographic characteristics
Angiographic characteristics and procedural information were
recorded. The procedure was done by either radial or femoral
approach (at operator’s discretion) immediately without delay.
Unfractionated heparin bolus (60–70 U/kg) was given during
the procedure. The target level of activated clotting time after
10 min was maintained at 250–350 s. Details of number of
diseased vessels, infarct‑related artery (IRA), and postprocedure
thrombolysis in myocardial infarction (TIMI) grade flow were
recorded. Angiographic or anatomical success was defined as
the attainment of a residual diameter stenosis <20% and normal
epicardial flow based on TIMI-flow grade.
Echocardiographic findings
Echo was performed during hospitalization and at 6‑month
clinical follow‑up. All echocardiographic examinations
were performed using Philips echo machine (model number
UTAP20W) with 2.5–3.5 MHz transducers. The left ventricular
ejection fraction (LVEF) was calculated according to modified
Simpson’s method. The 17‑segment model was used for
scoring the severity of segmental wall motion abnormalities
by wall motion score index according to the American Society
of Echocardiography.[12]
Statistical analysis
Statistical analysis was done using SPSS (Statistical Package
for the Social Science) version 17.0 (SPSS Inc., Chicago, IL,
USA). Continuous variables were expressed as mean ± standard
deviation and categorical variables as percentages. Continuous
variables were assessed by Student’s t‑test. Correlation analysis
was done by Spearman’s correlation analysis. The association of
mortality and anatomical success with plausible risk factors was
performed using Chi‑square/Fisher’s exact test. The odds ratio
and 95% confidence interval of variables with angiographic
success were also calculated. The odds ratio of outcomes were
not determined due to small or empty cell. The Chi‑square
test was used to compare the numerical variables. Six‑month
cumulative survival rates were assessed with the Kaplan–Meier
curve. P < 0.05 was considered statistically significant.
Results
A total of 50 patients with STEMI aged ≥75 years who fulfilled
the eligibility criteria were included in the study [Figure 1].
Baseline characteristics
The age of the patients ranged from 75 to 90 years. The mean
age of the study population was 78.32 ± 3.182. Thirty‑one
patients (62%) were male, and 19 patients (38%) were female.
Hypertension and smoking were the most common risk factors
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Gautam, et al.: Primary angioplasty in elderly Indian population

STEMI
Age≥75 years

Time >12 h

Delayed PCI
Within 12 hours (n = 68)

Excluded
Primary PCI

Inability to receive DAPT, LMCA involvement, mechanical complications of MI requiring

surgical intervention, any malignancy, life expectancy less than 1 year, cardiogenic
shock, rheumatic heart disease, history of coronary artery bypass grafting (CABG),
refusal to consent

Yes (n = 18) No

Excluded Included in the study (n = 50)

Mortality during index Discharged successfully

hospitalization (n = 4) (n = 46)

Mortality during Completing 6-month

follow-up period (n = 1) follow-up (n = 45)

Figure 1: Study flowchart.

in our study, each seen in 19 patients (38%). The baseline
demographic characteristics, comorbidities, and risk factors
of the study participants are summarized in Table 1.
The most common presentation was anterior wall myocardial
infarction (AWMI) in 52% of the patients. Most of the patients
who presented with AWMI had moderate‑to‑severe left
ventricular systolic dysfunction (LVSD) and higher Killip class
compared to inferior wall myocardial infarction (IWMI). Six
patients (12%) had complete heart block (CHB) at the time of
presentation. It was seen more commonly with IWMI. Most
of the patients (72%) presented in Killip Class I. Cardiogenic
shock was one of the exclusion criteria, and none of the
patients with Killip Class IV were included in our study. Four
patients (8%) presented in Killip class III; out of these four
patients, three patients expired within 48 h of hospitalization.
Delayed presentation (>6 h of chest pain) was seen in twenty
patients (40%). Almost half of the patients (46%) presented
in the emergency department with moderate‑to‑severe LVSD.
The mean LVEF% at presentation was 39.48 ± 5.97, and it
was 44.62 ± 5.56 at 6 months. Improvement in LVEF was
statistically significant (P < 0.001). Patients who presented
with AWMI had more improvement in LVEF compared to
patients with IWMI. The baseline clinical characteristics of
the study participants are shown in Table 2.
Angiographic characteristics
Almost half of the patients (48%) had triple‑vessel
disease (TVD). The most common IRA was left anterior
descending artery (LAD) in 26 patients (52%). Plain balloon
angioplasty (POBA) was done in five patients (10%) who
had complex lesion morphology and severe calcified
vessels. Out of these five patients who underwent POBA,
three patients had involvement of the right coronary
artery (RCA) and two patients had involvement of LAD
as IRA. The average number of stents used in PCI was
1.26 per procedure. Angiographic success (TIMI‑3
flow) was achieved in 39 patients (78%). The slow‑flow

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Gautam, et al.: Primary angioplasty in elderly Indian population

phenomenon (TIMI‑2) was seen in six patients (12%), and We analyzed the clinical outcomes in terms of the composite
the no‑reflow phenomenon (TIMI‑0 and TIMI‑1) was seen of death from any cause, MI, TVR, and stroke at the time of
in five patients (10%). The angiographic characteristics of index hospitalization as well as at 6‑month follow‑up. The
the patients are summarized in Table 3. inhospital and 6‑month adverse events are shown in Table 4
and Figure 2. In this study, inhospital mortality rate was 8%,
Clinical outcomes and during the follow‑up period, it was 2%. The survival rate
at 6 months was 90% in this study. The Kaplan–Meier estimate
of cumulative inhospital and 6‑month survival rate is shown
Table 1: Demographic characteristics, comorbidities, and in Figure 3.
risk factors
Baseline characteristics Prevalence (n=50), n (%)
Predictors of angiographic success and inhospital
Age (years), mean±SD 78.32±3.182
mortality
Sex In this study, diabetes and delayed presentation were associated
Male 31 (62) with slow‑flow and no‑reflow phenomenon. We found that
Female 19 (38) predictors of inhospital mortality were CHB at presentation,
Risk factors Killip class III, delayed presentation (>6 h), moderate‑to‑severe
Diabetes 18 (36) LVSD, postprocedure TIMI flow <3, history of diabetes, and
Hypertension 19 (38) nonresolution of ST segment (P < 0.05). Inhospital mortality
Smoking 19 (38) was not significantly associated with patients’ age, number
Dyslipidemia 14 (28) of diseased vessels, and IRA (P > 0.05). The predictors of
Past medical history angiographic success and inhospital mortality are summarized
MI 4 (8) in Tables 5 and 6.
PCI 4 (8)
CVA 2 (4)
CABG 0
Discussion
CKD 0 Elderly patients are less likely to receive coronary
AF 5 (10) revascularization when compared to their younger
MI: Myocardial infarction, PCI: Percutaneous coronary intervention, counterparts.[6] An elderly population presents numerous
CVA: Cerebrovascular accident, CABG: Coronary artery bypass grafting, challenges to the interventional cardiologist in the form of
CKD: Chronic kidney disease, AF: Atrial fibrillation, SD: Standard
deviation advanced complex coronary disease and multiple comorbidities.
In addition, data are lacking on the periprocedural and
long‑term outcomes.[13,14] Elderly patients were frequently
Table 2: Baseline clinical characteristics excluded or underrepresented in randomized trials that resulted
Clinical characteristics (n=50) Prevalence in a lack of evidence regarding the best treatment for this
STEMI specific population. In this study, we discussed immediate‑ and
AWMI 26 (52) short‑term outcomes of primary PCI in elderly patients
IWMI 23 (46) aged ≥75 years and correlated with their various clinical and
LWMI 1 (2) angiographic characteristics.
Killip class
Regarding procedural aspects, the femoral approach was used
I 36 (72)
in most of the patients (88%), whereas radial approach was
II 10 (20)
used in six patients (12%). The radial access is superior to
III 4 (8)
IV 0
the femoral access, but this approach can be more difficult in
CHB 6 (12)
CHB with AWMI 2 (4) 10%

CHB with IWMI 4 (8) 9%

(n=4)
8%
LVEF (%)
7%
At presentation 39.48±5.97
6%
At 6‑month follow‑up 44.62±5.56
5%
(n=2) (n=2)
Time from symptom onset to PCI (h) 4%
≤6 30 (60) 3%
(n=1) (n=1)(n=1)(n=1) (n=1)(n=1)(n=1)
>6 20 (40) 2%
ST‑segment resolution 42 (84) 1%
0 0
AWMI: Anterior wall myocardial infarction, IWMI: Inferior wall 0%
myocardial infarction, LWMI: Lateral wall myocardial infarction, CHB: Index hospitalization At follow-up
Complete heart block, LVEF: Left ventricular ejection fraction, PCI: Mortality MI TVR Stroke Major bleeding Minor bleeding
Percutaneous coronary intervention, STEMI: ST‑segment elevation
myocardial infarction Figure 2: Inhospital and 6‑month adverse events.

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Gautam, et al.: Primary angioplasty in elderly Indian population

100%
Table: 3 Angiographic characteristics
80% 92% 92% 92% 90% 90% 90% 90% Angiographic variables (n=50) Prevalence, n (%)
Survival

60% Catheterization access

40% Radial 6 (12)
Femoral 44 (88)
20%
Disease extension
0% SVD 13 (26)
0 30 60 90 120 150 180
Follow-up days
DVD 13 (26)
TVD 24 (48)
Figure 3: Kaplan–Meier estimate of cumulative inhospital and 6‑month Infarct‑related artery
survival rate. LAD 26 (52)
RCA 20 (40)
elderly patients in primary PCI setting and is associated with LCX 4 (8)
higher failure rates and access site crossover.[15] However, Type of angioplasty
elderly patients also have a higher risk of bleeding with POBA 5 (10)
femoral access.[16] In our study, the femoral access was PCI with stent implantation 45 (90)
associated with lower rate of local site complications. Only Average number of stents 1.26±0.17
two patients (4%) had vascular access groin hematoma, Average length of stents (mm) 32±14
Thrombus aspiration 11 (22)
which was managed conservatively without any surgical
Postprocedural TIMI flow
intervention.
TIMI‑3 39 (78)
All the patients were anticoagulated with unfractionated TIMI‑2 6 (12)
heparin. In seven patients (14%), we used glycoprotein IIb/IIIa TIMI‑1 5 (10)
receptor inhibitor, and they had high thrombus burden. None TIMI‑0 0
of the patients were anticoagulated with bivalirudin. However, IABP 0
its use would be more attractive in elderly population due to Use of continues inotropic infusion during procedure 0
their higher bleeding risk.[17] The use of low‑molecular‑weight Staged PCI of nonculprit lesion 10 (20)
heparin was avoided in elderly patients because of their low SVD: Single‑vessel disease, DVD: Double‑vessel disease, TVD:
Triple‑vessel disease, LAD: Left anterior descending artery, RCA:
creatinine clearance. Prasugrel was not administered in any of Right coronary artery, LCX: Left circumflex, POBA: Plain old balloon
the patients due to advanced age. We used clopidogrel in all angioplasty, TIMI: Thrombolysis in myocardial infarction, IABP:
patients along with aspirin. However, ticagrelor appears as an Intra‑aortic balloon pump, PCI: Percutaneous coronary intervention
interesting alternative to clopidogrel.[18,19]
In our study, four patients (8%) expired within 48 h of Table 4: Inhospital and follow‑up adverse events
procedure. Out of these, one patient had hemorrhagic Variables Frequency, n (%)
stroke (major bleeding) and other three patients had no
Mortality
reflow with persistent severe LVSD. Later on, they developed Index hospitalization 4 (8)
refractory cardiogenic shock, leading to inhospital mortality. At follow‑up 1 (2)
Out of 46 survived cases, one patient (2%) developed stent MI
thrombosis in the left circumflex artery during hospitalization. Index hospitalization 1 (2)
He was immediately taken up for revascularization by At follow‑up 1 (2)
thrombosuction without any additional stent implantation. TVR
He was discharged successfully later on. Two patients (4%) Index hospitalization 1 (2)
had TIMI minor bleeding in the form of vascular access groin At follow‑up 1 (2)
hematoma. Both the patients were managed medically without Stroke
any need of blood transfusion. Index hospitalization 1 (2)
At follow‑up 0
During the follow‑up period, one patient (2%) expired after Major bleeding
3 months, probably because of persisting severe LVSD. His Index hospitalization 1 (2)
LVEF was 30% at the time of the procedure and remained At follow‑up 0
the same at 2‑month follow‑up. Another patient (2%) had Minor bleeding
stent thrombosis at the end of 2 months. He presented with Index hospitalization 2 (4)
chest pain in the emergency and was taken up for immediate At follow‑up 2 (4)
revascularization of LAD with thrombosuction without MI: Myocardial infarction, TVR: Target vessel revascularization
implantation of any additional stent, successfully discharged
later. None of the patients had stroke or major bleeding patients (4%): one patient had hematuria and the other patient
during follow‑up period. Minor bleeding was seen in two had epistaxis which subsided on its own.

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Gautam, et al.: Primary angioplasty in elderly Indian population

Table 5: Predictors of angiographic success

Variables Anatomical success rate, n (%) P OR (95% CI)
Sex
Male (n=31) 25 (80.64) 0.564 1.45 (0.38‑5.77)
Female (n=19) 14 (73.68) 1.00
Diabetes
Yes (n=18) 11 (61.11) 0.018 0.22 (0.06‑0.092)
No (n=32) 28 (87.50) 1.00
Hypertension
Yes (n=19) 17 (89.47) 0.125 3.47 (0.66‑18.25)
No (n=31) 22 (70.96) 1.00
Smoking
Yes (n=19) 17 (89.47) 0.125 3.47 (0.66‑18.25)
No (n=31) 22 (70.96) 1.00
Dyslipidemia
Yes (n=14) 10 (71.42) 0.182 0.50 (0.11‑2.13)
No (n=36) 30 (83.33) 1.00
Time from symptom onset to PCI (h)
≤6 (n=30) 29 (96.66) <0.001 29 (3.29‑255.9)
>6 (n=20) 10 (50) 1.00
Site of MI*
AWMI (n=26) 18 (69.23) 0.390 ‑
IWMI (n=23) 20 (86.95) ‑
LWMI (n=1) 1 (100) ‑
LVEF percentage at presentation
<40% (n=27) 16 (69.56) 0.052 0.40 (0.10‑1.59)
≥40% (n=23) 23 (85.18) 1.00
IRA*
LAD (n=26) 18 (69.36) 0.124 ‑
LCX (n=4) 4 (100) ‑
RCA (n=4) 17 (82.00) ‑
*Unadjusted estimate cannot be estimated due to empty cells. MI: Myocardial infarction, IRA: Infarct‑related‑artery, OR: Odds ratio, CI: Confidence interval,
LAD: Left anterior descending artery, RCA: Right coronary artery, LCX: Left circumflex, PCI: Percutaneous coronary intervention, AWMI: Anterior wall
myocardial infarction, IWMI: Inferior wall myocardial infarction, LWMI: Lateral wall myocardial infarction, LVEF: Left ventricular ejection fraction

In our study, inhospital mortality rate was 8%, and during
the follow‑up period, it was 2%. Since we had excluded
the patients who were in cardiogenic shock at the time of
presentation, hence the mortality rate was lower compared to
other studies.[20,21]
Noohi et al.[20] in their retrospective study included 100
primary PCI patients aged ≥75 years. They had shown that
inhospital mortality was 2.4% in patients without cardiogenic
shock and 83% in those with cardiogenic shock. They also
found that the mortality rate during 6‑month follow‑up period
was 2%.
Valente et al.[21] in their prospective study assessed short‑ and
long‑term outcomes of 88 elderly patients aged ≥85 years
in Italy, who underwent primary PCI, and they found that
inhospital mortality was 17%. They found that the mortality
rate was significantly higher in patients with cardiogenic
shock, poor postprocedure TIMI flow, Killip Class ≥III on
admission, and chronic renal failure. Major bleeding occurred
in 11 patients (12%), mostly vascular access groin hematoma.
Compared to their study, we found low inhospital mortality
rate (8%), because we had excluded the patients with
cardiogenic shock.
In our study, we found that predictors of inhospital mortality
were CHB at presentation, Killip Class III, delayed
presentation (>6 h), moderate‑to‑severe LVSD, postprocedure
TIMI flow <3, history of diabetes, and nonresolution of ST
segment.
Six patients (12%) presented with CHB. It was seen more
commonly with IWMI. Out of these six patients, four patients
had IWMI and two patients had AWMI. Both the patients
of CHB with AWMI expired during index hospitalization.
They had severe ostial LAD stenosis and persistent severe
LVSD. One patient of CHB with IWMI expired. He had
super‑dominant RCA and did not achieve TIMI‑3 flow after
the procedure. The rest three patients of CHB with IWMI
normalized to sinus rhythm after the procedure, and they were
discharged successfully. CHB at presentation was one of the
predictors of inhospital mortality in our study. Tok et al.[22]
determined clinical outcome of patients older than 75 years
who were treated with primary PCI in their retrospective

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Gautam, et al.: Primary angioplasty in elderly Indian population

study. They found that atrioventricular block was one of the

Table 6: Predictors of inhospital mortality
independent predictors of mortality.
Variables Inhospital P
mortality rate (%) In our study, the maximum number of patients (60%, n = 30)
Age groups (years) presented within 6 h of chest pain. Delayed presentation
75‑79 12.5 0.156 (>6 h of chest pain) was significantly associated with inhospital
80‑84 0 mortality. Most of the patients who had delayed presentation
≥85 0 had a higher killlip class. Delay from symptoms to primary
Sex PCI was a result of multiple factors including difficulties in
Male 6.4 0.147 diagnosis, atypical presentations, nondiagnostic ECG changes,
Female 10.52 and sometimes refusal from other health‑care providers to
Diabetes perform interventional procedures in elderly patients.[23]
Yes 22.22 0.013
Hernández et al.[24] also found that delayed presentation (>6 h)
No 0
was an independent predictor of inhospital mortality in their
Hypertension
Yes 0 0.130
retrospective study.
No 12.9 Cardiogenic shock was one of the exclusion criteria in our
Smoking study and none of the patients with Killip Class IV were
Yes 0 0.137
included. Patients who presented with AWMI had higher Killip
No 12.9
class compared to IWMI. Killip Class III is one of the major
Dyslipidemia
Yes 9.1 0.184
predictors of short‑term mortality in our study. The mortality
No 6.2 rate was 2.7%, 0%, and 75% in Killip Class I, Killip Class II,
Site of MI and in Killip Class III, respectively, in our study. Noohi et al.[20]
AWMI 11.45 0.643 found that 18% of the elderly primary PCI patients presented
IWMI 4.35 with cardiogenic shock in their retrospective study, and they
LWMI 0 found that it was an independent predictor of inhospital
CHB at presentation mortality. None of the patients had systolic blood pressure <90
Yes 50 0.04 mmHg during the procedure in our study, so neither continuous
No 2.3 inotropic support nor intra‑aortic balloon pump support was
Killip class
required during the procedure.
Killip III 75 <0.001
Killip I/II 2.2 Angiographic success was achieved in 39 patients (78%). All
Time from symptom onset to PCI (h) the four patients who expired during index hospitalization
>6 20 0.021 had not achieved TIMI‑3 flow. Noohi et al.[20] had shown
≤6 0 that postprocedure TIMI‑3 flow was achieved in 73% of
LVEF (%)
the patients, and Claessen et al.[9] found postprocedural
≥40 0 0.002
TIMI‑3 flow in 78% of the elderly patients who underwent
<40 17.4
IRA
primary PCI. Diabetes and delayed presentation were
LAD 11.5 0.092 associated with slow‑flow or no‑reflow phenomenon in our
LCX 0 study. Noohi et al.[20] also found that anatomical success
RCA 5.0 is significantly associated with procedural success in their
Number of diseased vessel retrospective analysis. Moonen et al.[25] had also shown
SVD 7.7 0.210 that postprocedure TIMI flow was significantly associated
DVD 0 with mortality.
TVD 12.5
Postprocedure TIMI flow Moderate‑to‑severe LVSD at presentation was significantly
0/1 80 <0.001 associated with inhospital mortality. Bromage et al.[26] also
2 0 found that poor left ventricular function was an independent
3 0 predictor of mortality in octogenarian patients with STEMI
ST‑segment resolution treated with primary PCI in their retrospective study.
Yes 0 <0.001
No 50
The elderly patients are at increased risk of contrast‑induced
SVD: Single‑vessel disease, DVD: Double‑vessel disease, TVD: Triple‑ nephropathy. Iodinated contrast agents increase the risk of
vessel disease, LAD: Left anterior descending artery, RCA: Right contrast‑induced acute renal failure (ARF), and it is aggravated
coronary artery, LCX: Left circumflex, TIMI: Thrombolysis in myocardial by the frequent Killip III/IV presentation with associated organ
infarction, PCI: Percutaneous coronary intervention, AWMI: Anterior wall
myocardial infarction, IWMI: Inferior wall myocardial infarction, LWMI:
hypoperfusion. In our study, we selectively used isosmotic
Lateral wall myocardial infarction, CHB: Complete heart block, IRA: nonionic contrast agent (iodixanol [Visipaque]) in every
Infarct‑related‑artery, LVEF: Left ventricular ejection fraction patient. However, even though ARF had developed in five

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Gautam, et al.: Primary angioplasty in elderly Indian population
patients (10%) during the hospital stay, this was transient and
it recovered on its own. It is important to note that no death
resulted from renal failure and none of the patients required
hemodialysis.
In our study, half of the patients had TVD and more advanced
complex coronary lesions with arterial calcification. We did
angioplasty of culprit lesions only in primary PCI setting.
None of the patients had undergone nonculprit PCI lesion
in the same setting or during index hospitalization. We have
addressed nonculprit lesion PCI in patients who had angina or
had evidence of significant ischemic burden on investigations
during follow‑up period. The most common nonculprit
vessel was RCA. Ten patients (20%) had undergone staged
PCI of nonculprit lesions. We used only drug‑eluting stents
in our study. We avoided high‑pressure dilatation following
stenting to decrease the incidence of slow‑flow or no‑reflow
phenomenon. Patients’ age, site of MI, number of diseased
vessels, and IRA were not associated with major adverse
cardiac events.
We conclude favorable immediate‑ and short‑term outcomes
of primary PCI among elderly populations who presented
with STEMI. This study suggests that primary PCI can
be safely and successfully performed in elderly patients
presenting with STEMI in Indian population. To the best
of our knowledge, this is the first prospective study on
outcomes of primary PCI in elderly patients aged ≥75 years
from India.
Limitations
Small sample size and exclusion of the patients with
cardiogenic shock at the time of presentation are the major
limitations of our study.
Conclusions
PCI is a more challenging procedure in the elderly population
because of complex coronary lesions, comorbidities, and
frailty. There is frequent delay in presentation of these patients
to hospital after onset of symptoms and efforts should be
undertaken to shorten this period. The transradial approach
may be routinely chosen to reduce puncture site‑related
bleeding complications. Primary PCI can be safely and
successfully performed in this population with acceptable
rate of complications. Further prospective studies involving
larger number of elderly patients and newer antithrombotic
approaches may help to better define the risk and benefit ratio
of primary PCI in elderly patients with acute STEMI.
Acknowledgement
We are thankful to Dr Rajeev Kumar Malhotra, Scientist
(statistician), Delhi cancer registry, Dr B.R.A. IRCH, AIIMS,
Delhi for statistical analysis.
Ethical clearance
The institutional ethical committee has approved the study
protocol.
160 Journal of the Practice of Cardiovascular Sciences ¦ Volume 6 ¦ Issue 2 ¦ May-August 2020
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Miura T, Soga Y, Aihara H, Yokoi H, Iwabuchi M. Prevalence and
clinical outcome of polyvascular atherosclerotic disease in patients
undergoing coronary intervention. Circ J 2013;77:1349.
2. Puymirat E, Simon T, Steg PG, Schiele F, Guéret P, Blanchard D, et al.
Association of changes in clinical characteristics and management with
improvement in survival among patients with ST‑elevation myocardial
infarction. JAMA 2012;308:998‑1006.
3. Hermans MP, Eindhoven DC, van Winden LA, de Grooth GJ, Blauw GJ,
Muller M, et al. Frailty score for elderly patients is associated with
short‑term clinical outcomes in patients with ST‑segment elevated
myocardial infarction treated with primary percutaneous coronary
intervention. Neth Heart J 2019;27:127‑33.
4. Arisha MJ, Ibrahim DA, Abouarab AA, Rahouma M, Kamel MK,
Baudo M, et al. Percutaneous coronary intervention in the elderly.
Vessel Plus 2018;2:14.
5. Guagliumi G, Stone GW, Cox DA, Stuckey T, Tcheng JE, Turco M,
et al. Outcome in elderly patients undergoing primary coronary
intervention for acute myocardial infarction: Results from the
Controlled Abciximab and Device Investigation to Lower Late
Angioplasty Complications (CADILLAC) trial. Circulation
2004;110:1598‑604.
6. Petroni T, Zaman A, Georges JL, Hammoudi N, Berman E, Segev A,
et al. Primary percutaneous coronary intervention for ST elevation
myocardial infarction in nonagenarians. Heart 2016;102:1648‑54.
7. Alexander KP, Newby LK, Armstrong PW, Cannon CP, Gibler WB,
Rich MW, et al. Acute coronary care in the elderly, part II:
ST‑segment‑elevation myocardial infarction: A scientific statement for
healthcare professionals from the American Heart Association Council
on Clinical Cardiology: In collaboration with the Society of Geriatric
Cardiology. Circulation 2007;115:2570‑89.
8. Koutsoukis A, Kanakakis I. Challenges and unanswered questions in
STEMI management. Hellenic J Cardiol 2019;60:211‑5.
9. Claessen BE, Kikkert WJ, Engstrom AE, Hoebers LP, Damman P,
Vis MM, et al. Primary percutaneous coronary intervention for ST
elevation myocardial infarction in octogenarians: Trends and outcomes.
Heart 2010;96:843‑7.
10. O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., Chung MK,
de Lemos JA, et al. 2013 ACCF/AHA guideline for the management
of ST‑elevation myocardial infarction: Executive summary: A report
of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines. Circulation
2013;127:529‑55.
11. Banez B, James S, Agewall S, Antunes MJ, Bucciarelli DC, Bueno H,
et al. ESC guidelines for the management of acute myocardial
infarction in patients presenting with ST‑segment elevation. Eur Heart J
2018;39:119‑77.
12. Lang RM, Badano LP, Mor‑Avi V, Afilalo J, Armstrong A, Ernande L,
et al. Recommendations for cardiac chamber quantification by
echocardiography in adults: An update from the American Society of
Echocardiography and the European Association of Cardiovascular
Imaging. J Am Soc Echocardiogr 2015;28:1‑3.9E+15.
13. Kaehler J, Meinertz T, Hamm CW. Coronary interventions in the elderly.
Heart 2006;92:1167‑71.
14. Liistro F, Angioli P, Falsini G, Ducci K, Baldassarre S, Burali A, et al.
Early invasive strategy in elderly patients with non‑ST elevation acute
coronary syndrome: Comparison with younger patients regarding
30 day and long term outcome. Heart 2005;91:1284‑8.
15. Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T, et al.
Radial versus femoral access in patients with acute coronary syndromes
undergoing invasive management: A randomised multicentre trial.
Lancet 2015;385:2465‑76.
[Downloaded free from http://www.j-pcs.org on Friday, August 28, 2020, IP: 95.148.139.104]
Gautam, et al.: Primary angioplasty in elderly Indian population
16. Karrowni W, Vyas A, Giacomino B, Schweizer M, Blevins A,
Girotra S, et al. Radial versus femoral access for primary percutaneous
interventions in ST‑segment elevation myocardial infarction patients:
A meta‑analysis of randomized controlled trials. JACC Cardiovasc
Interv 2013;6:814‑23.
17. Stone GW, Mehran R, Goldstein P, Witzenbichler B, Van’t Hof A,
Guagliumi G, et al. Bivalirudin versus heparin with or without
glycoprotein IIb/IIIa inhibitors in patients with STEMI undergoing
primary percutaneous coronary intervention: Pooled patient‑level
analysis from the HORIZONS‑AMI and EUROMAX trials. J Am Coll
Cardiol 2015;65:27‑38.
18. Cayla G, Cuisset T, Silvain J, Henry P, Leclercq F, Carrié D, et al. Platelet
function monitoring in elderly patients on prasugrel after stenting for an
acute coronary syndrome: Design of the randomized antarctic study. Am
Heart J 2014;168:674‑81.
19. Schmucker J, Fach A, Marin LA, Retzlaff T, Osteresch R, Kollhorst B.
Efficacy and safety of ticagrelor in comparison to clopidogrel in elderly
patients with ST‑Segment–elevation myocardial infarctions. J Am Heart
Assoc 2019;8:18.
20. Noohi F, Hashemi I, Sanati HR, Peighambari MM, Kiavar M,
Maadani M, et al. In‑hospital and six‑month outcomes of elderly
patients undergoing primary percutaneous coronary intervention
for acute ST‑elevation myocardial infarction. ARYA Atheroscler
2016;12:28‑34.
Journal of the Practice of Cardiovascular Sciences ¦ Volume 6 ¦ Issue 2 ¦ May-August 2020
21. Valente S, Lazzeri C, Salvadori C, Chiostri M, Giglioli C, Poli S, et al.
Effectiveness and safety of routine primary angioplasty in patients aged
≥85 years with acute myocardial infarction. Circ J 2008;72:67‑70.
22. Tok D, Turak O, Ozcan F, Durak A, Cağlı K, Başar N, et al. Primary
percutaneous coronary intervention for acute myocardial infarction
in elderly aged 75 years and over: Lin‑hospital mortality and clinical
outcome. Arch Turk Soc Cardiol 2012;40:565‑73.
23. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al.
ESC Guidelines for the management of acute coronary syndromes in
patients presenting without persistent ST‑segment elevation: The task
force for the management of acute coronary syndromes (ACS) in patients
presenting without persistent ST‑segment elevation of the European
Society of Cardiology (ESC). Eur Heart J 2011;32:2999‑3054.
24. Hernández JM, Brugaletta S, Joan A, Jose A, Prado A, Palop R, et al.
Primary angioplasty in patients older than 75 years. Profile of patients
and procedures, outcomes, and predictors of prognosis in the ESTROFA
IM + 75 registry. Rev Esp Cardiol 2017;70:81‑7.
25. Moonen LA, van’t Veer M, Pijls NH. Procedural and long‑term outcome
of primary percutaneous coronary intervention in octogenarians. Neth
Heart J 2010;18:129‑34.
26. Bromage DI, Jones DA, Rathod KS, Grout C, Iqbal MB, Lim P,
et al. Outcome after primary percutaneous coronary intervention in
octogenarians. J Am Heart Assoc 2016;5:e003027.
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