Outcome and Complications Following Diagnostic Cardiac Catheterisation in Older People

Jenny Walsh Radiology Specialist Registrar; Mark Hargreaves Consultant Cardiologist, Pennine Acute NHS Trust

Disclosures

Br J Cardiol. 2014;21(1):1-4. 

In This Article

Discussion

In older patients we observed that DCC is safe, and contributes to clinical management in a similar way to that seen in younger patients.

Following DCC, 52% of our older group were referred for revascularisation as the 'primary outcome' compared with 40% of younger patients. These findings are similar to previous reports of revascularisation rates in older cohorts: Thompson et al.[2] reported that, in patients aged over 75 years of age, 31% and 28% of Canadian men were referred for bypass surgery (CABG) and PCI, respectively. The corresponding values for older Canadian women were 18% and 29%, and the overall referral rates for revascularisation were comparable with a younger cohort. Niebauer et al.[3] reported referral rates of 31% and 35%, respectively, for CABG and PCI from 1,085 consecutive patients aged over 80 years.

Primary treatment decision was generally determined by an interventional cardiologist and patient. Secondary outcome was generally determined by the interventional cardiologist and surgeon in the context of an informal multi-disciplinary team (MDT).

Before the widespread introduction of PCI, Elder et al.[4] compared 'primary' and 'secondary' outcomes from DCC in patients aged over 70 years with suspected CAD. The findings were compared with patients aged under 70 years. Referral rates ('primary outcome') for revascularisation (predominantly CABG) were 48% and 42% for the older and younger cohorts, respectively.

We made a distinction between the 'primary outcome', based on the management plan immediately following DCC, and the treatment actually received, which we termed 'secondary outcome'. Thus, 'primary outcome' would, in most instances, be determined by the cardiologist performing the DCC and would be heavily influenced by the coronary anatomy itself. The 'primary outcome' would often be recorded before consultation with the patient and without detailed knowledge of comorbidity, or patient preference. Perhaps, most importantly, the 'primary outcome' would be recorded before formal consultation with surgical colleagues, perhaps explaining why a significant proportion of these patients were subsequently considered unsuitable for CABG. Despite these considerations, we found that a similar proportion of patients from each age group ultimately underwent revascularisation. Compared with the older age group, almost all patients from the younger age group received the allocated 'primary outcome' decision, whether this was revascularisation or medical therapy.

In Elder's study,[4] the majority of patients (246 from 268) received the 'primary outcome' decision; thus, in the older cohort, only four patients from the 57 referred for CABG (primary outcome) did not eventually undergo surgery. In our older cohort, only six from 27 patients referred for surgery received the 'primary outcome' decision, perhaps reflecting both the advanced age of our patient cohort and the availability of less invasive revascularisation options; two patients who were considered unfit for surgery subsequently received PCI.

We observed that half of our older patients who did not receive surgery (as 'primary outcome') were dead within three years. Thompson et al.[2] reported that the outcome of patients who did not undergo proposed surgery (as 'primary outcome') was poor, and considerably worse when compared with those patients who did receive either PCI or medical therapy as their 'primary outcome'. Being considered unfit for surgery often reflects significant comorbidity, with advanced CAD, and ultimately a poor prognosis.[5]

Our older group were taking significantly more angina medications, had more documented cardiovascular risk factors, and presented more often as an emergency compared with the younger patient group. The older patients were also found to have more advanced CAD, and significantly more were referred for revascularisation. These findings are not unexpected given the predominant influence of age on cardiovascular risk profile and the natural history of CAD.

Complications rates associated with DCC were similar in both patient groups, with no strokes or deaths in the older patient group, and were consistent with previous studies.[3]

We agree that increasing the numbers would increase the overall strength of the study. However, in the context of an observational study, we feel that the relative group numbers (100 from 771 patients overall) were representative and that increasing group sizes would not materially affect the outcome.

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