Patient Age Not the Only Factor to Consider When Contemplating Percutaneous Coronary Intervention
Although percutaneous coronary intervention (PCI) has proven to be effective for treating stable angina in older adults, a patient’s age should not be the sole deciding factor for having the procedure, according to a study published in the Journal of the American College of Cardiology.
ORBITA-2 was the first randomized, placebo-controlled trial to demonstrate the efficacy of PCI for symptom relief in patients with stable angina and coronary artery disease without background antianginal medication. This secondary analysis of the study examined the relationship between age and severity of symptoms and stenosis in older patients.
PCI’s effects on older adults had not yet been defined, said Rasha K. Al-Lamee, MD, of the National Heart and Lung Institute at Imperial College London, Hammersmith Hospital Campus, London, England. To learn more, Al-Lamee and colleagues analyzed patient data from ORBITA-2.
“Given that the primary analysis showed that the PCI’s effect was greatest with little or no prior antianginal therapy, we wanted to see if we could target upfront PCI for patients who would stand to benefit the most,” Al-Lamee told Medscape Medical News. “We explored whether age was a key factor in decision-making and if antianginal medication therapy should be considered prior to PCI for older individuals. The study team also investigated if it was prudent to offer PCI strictly to patients who remained symptomatic.”
Statistical Power
Researchers administered a patient questionnaire and evaluated results from stress echocardiography testing and treadmill time. The research team designed and built a smartphone application for patients to input symptoms daily. Questions in the app pertain to the previous day and inquire about whether patients experienced angina and the frequency and severity of the episodes.
“The ORBITA app allowed us to quantify the true daily burden of angina,” Al-Lamee said. “The remote data collection meant that we only lost 0.3% of the data, which is quite remarkable, especially as the study was conducted during the COVID pandemic. Daily data collection enabled us to define the timepoint at which PCI was effective and to monitor this throughout the trial.”
The daily collection also increased the statistical power of the trial and allowed researchers to perform multiple secondary analyses to test the predictors of angina relief with PCI,” Al-Lamee added.
In a cohort of 301 older adult patients with an average age of 64 years, the study team found a modest link between age and severity of symptoms and stenosis. However, they observed that PCI was more effective in relieving symptoms in older patients than in younger ones, while its impact on treadmill time was significantly greater in younger patients than in older ones.
Noncardiac Factors
Experts consider exercise time a robust endpoint for trials testing the efficacy of medications and devices targeting symptom relief, Al-Lamee said. However, she acknowledged that the endpoint has limitations.
“Exercise capacity can be influenced by many factors that are noncardiac, and it is not always strongly related to angina,” she said. “This is even more relevant for older patients whose physical activity may be limited by medical conditions such as osteoarthritis. If we want the results of our trials to be widely applicable, we need to choose endpoints that are inclusive and capture the problems that patients seek to address.”
In an accompanying editorial, Michael G. Nanna, MD, MHS, from the Section of Cardiovascular Medicine at Yale School of Medicine in New Haven, Connecticut, and colleagues concurred that several factors can modify the benefit of PCI for older adults. Besides osteoarthritis, “many older patients have multiple chronic conditions that can affect symptoms and outcomes more than coronary disease itself,” he said.
Limited Results?
“Coronary disease in this population is often diffuse and heavily calcified, which can limit the durability of PCI results,” Nanna said. In addition, he said, symptoms such as shortness of breath or fatigue may be related to microvascular disease, diastolic dysfunction, or deconditioning rather than a focal blockage. — Michael G. Nanna, MD, MHS
“This means that opening a single artery may not lead to meaningful improvement,” he said. “Finally, the need for long-term antiplatelet therapy and the higher risk for bleeding can offset potential gains, particularly when symptoms are mild or intermittent.”
For older adults, shared decision-making is paramount for recognizing that PCI in this population is highly individualized and sensitive to preference, he said. The focus should be on understanding what matters most to the patient, Nanna said. Examples include symptom relief, maintaining independence, or minimizing procedural and medication-related risks. It also requires being clear about what PCI can realistically achieve.
“The goal is a shared, informed decision that aligns treatment intensity with the patient’s values, overall health, and anticipated benefit rather than relying solely on angiographic findings,” he said.
Al-Lamee reported serving on the advisory boards for Janssen Pharmaceuticals, Abbott, Shockwave, Medtronic, AstraZeneca, Cathworks, and Philips. She reported receiving speaker fees from Abbott, Philips, Shockwave, Medtronic, Servier, Shockwave, and Menarini. She also reported serving as a company director of ORBITA Systems Ltd.
Nanna reported receiving unrelated current research support from the American College of Cardiology Foundation, supported by the George F. and Ann Harris Bellows Foundation, the Patient-Centered Outcomes Research Institute, the Yale Claude D. Pepper Older Americans Independence Center, and the National Institute on Aging. He also reported receiving personal fees from Heartflow, Inc.; Merck; Novartis; and Novo Nordisk.
Martta Kelly is a medical journalist who lives in the New York metropolitan area.
