Quality of Life Following PCI in Octogenarians
Quality of Life Following PCI in Octogenarians
Objective Overall, percutaneous coronary intervention (PCI) can improve the symptoms and quality of life (QoL) of patients with coronary artery disease. Older patients account for an increasing number and proportion of PCIs, however they are more prone to adverse events. This study systematically reviews the QoL benefits in this sub-group.
Design and setting A systematic review was undertaken, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines, using Medline, Embase and Science Direct databases. The search was limited to studies available in English; last run on 31 December 2012.
Patients Patients aged ≥80 years.
Intervention PCI.
Main outcome measure QoL.
Results The process identified 11 articles which reported QoL outcomes in octogenarians following PCI. In total, there were 700 octogenarian patients identified within the 11 studies with a mean age of 82.9 years. Studies were heterogeneity in the populations, methodology and QoL tools utilised. Overall, the literature suggests that QoL for octogenarians improves following PCI. Older patients improve at least as much as younger patients and may gain more in the areas of physical functioning and improved angina status. The benefits are greatest in the first 6 months and may continue until at least 3 years.
Conclusions QoL following PCI in octogenarians improves at least as much as in younger patients. Given the small number of studies resulting in a total of 700 octogenarian patients, further studies would be useful in determining those octogenarian patients who are likely to derive the greatest benefit.
Reduced fertility rates and substantial rises in life expectancy at birth and at 65 years, have resulted in an increasingly older population. Coronary arterial disease (CAD) remains the most commonly reported limiting longstanding illness and accounts for more than a quarter of all deaths in both men and women. Mortality and morbidity from CAD are strongly associated with age. Among people aged 75 years and over, more than one-third of men and around one-quarter of women are living with CAD. CAD may be managed using medical therapy or with revascularisation techniques such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). As a result of the ageing population, older patients account for an increasing number and proportion of patients attending for management of CAD by PCI. Studies show that older patients undergoing PCI have a higher risk profile, in terms of co-morbid conditions, multivessel disease and arterial calcification, and suffer more adverse events than their younger counterparts.
Assessments of reductions in early and long-term adverse clinical outcomes (such as myocardial infarction) are important considerations following PCI. However, as PCI is generally undertaken to relieve the signs and symptoms of myocardial ischaemia, the effects on symptom relief and quality of life are more critical considerations for patient and health service decision-making. This is particularly pertinent in the older population as 'the longevity benefits (of PCI) are frequently limited by multiple competing risks and the goal of therapy is often to maintain independent living with reasonable comfort'. Health related quality of life (QoL) measures are increasing being used to assess the effectiveness of interventions in all age groups. Their use takes into consideration the impact of the intervention on the patients' physical health, emotional and social wellbeing.
There has been a previous systematic review which assessed clinical outcomes following PCI in octogenarians (e.g. death or major adverse cardiac events). This did not assess any impact on QoL. It demonstrated that PCI in octogenarians was well tolerated and associated with acceptable short-term and long-term outcomes. However, the authors described the evidence as of 'low quality' because of their small study sizes or observational nature—despite containing some large well conducted observational studies.
Another systematic review assessed the impact of drug-eluting coronary stents (DES) on QoL. This included studies which either excluded older patients altogether, or had very small numbers of those aged 80 years or older (eg, the RITA study). Its main focus was on healthcare costs and the impact of target vessel revascularisation (TVR) on QoL (DES are associated with a reduced need for TVR). It concluded that there was 'a lack of convergence in the literature' on costs and QoL improvements associated with DES.
This article aims to collate the available evidence by undertaking a systematic review and critical appraisal of the relevant studies which assess QoL following PCI in octogenarians.
Abstract and Introduction
Abstract
Objective Overall, percutaneous coronary intervention (PCI) can improve the symptoms and quality of life (QoL) of patients with coronary artery disease. Older patients account for an increasing number and proportion of PCIs, however they are more prone to adverse events. This study systematically reviews the QoL benefits in this sub-group.
Design and setting A systematic review was undertaken, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines, using Medline, Embase and Science Direct databases. The search was limited to studies available in English; last run on 31 December 2012.
Patients Patients aged ≥80 years.
Intervention PCI.
Main outcome measure QoL.
Results The process identified 11 articles which reported QoL outcomes in octogenarians following PCI. In total, there were 700 octogenarian patients identified within the 11 studies with a mean age of 82.9 years. Studies were heterogeneity in the populations, methodology and QoL tools utilised. Overall, the literature suggests that QoL for octogenarians improves following PCI. Older patients improve at least as much as younger patients and may gain more in the areas of physical functioning and improved angina status. The benefits are greatest in the first 6 months and may continue until at least 3 years.
Conclusions QoL following PCI in octogenarians improves at least as much as in younger patients. Given the small number of studies resulting in a total of 700 octogenarian patients, further studies would be useful in determining those octogenarian patients who are likely to derive the greatest benefit.
Introduction
Reduced fertility rates and substantial rises in life expectancy at birth and at 65 years, have resulted in an increasingly older population. Coronary arterial disease (CAD) remains the most commonly reported limiting longstanding illness and accounts for more than a quarter of all deaths in both men and women. Mortality and morbidity from CAD are strongly associated with age. Among people aged 75 years and over, more than one-third of men and around one-quarter of women are living with CAD. CAD may be managed using medical therapy or with revascularisation techniques such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). As a result of the ageing population, older patients account for an increasing number and proportion of patients attending for management of CAD by PCI. Studies show that older patients undergoing PCI have a higher risk profile, in terms of co-morbid conditions, multivessel disease and arterial calcification, and suffer more adverse events than their younger counterparts.
Assessments of reductions in early and long-term adverse clinical outcomes (such as myocardial infarction) are important considerations following PCI. However, as PCI is generally undertaken to relieve the signs and symptoms of myocardial ischaemia, the effects on symptom relief and quality of life are more critical considerations for patient and health service decision-making. This is particularly pertinent in the older population as 'the longevity benefits (of PCI) are frequently limited by multiple competing risks and the goal of therapy is often to maintain independent living with reasonable comfort'. Health related quality of life (QoL) measures are increasing being used to assess the effectiveness of interventions in all age groups. Their use takes into consideration the impact of the intervention on the patients' physical health, emotional and social wellbeing.
There has been a previous systematic review which assessed clinical outcomes following PCI in octogenarians (e.g. death or major adverse cardiac events). This did not assess any impact on QoL. It demonstrated that PCI in octogenarians was well tolerated and associated with acceptable short-term and long-term outcomes. However, the authors described the evidence as of 'low quality' because of their small study sizes or observational nature—despite containing some large well conducted observational studies.
Another systematic review assessed the impact of drug-eluting coronary stents (DES) on QoL. This included studies which either excluded older patients altogether, or had very small numbers of those aged 80 years or older (eg, the RITA study). Its main focus was on healthcare costs and the impact of target vessel revascularisation (TVR) on QoL (DES are associated with a reduced need for TVR). It concluded that there was 'a lack of convergence in the literature' on costs and QoL improvements associated with DES.
This article aims to collate the available evidence by undertaking a systematic review and critical appraisal of the relevant studies which assess QoL following PCI in octogenarians.
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