How Age Shapes Treatment Decisions in Chronic Coronary Disease

For many older adults with heart disease, age is a significant factor in decisions about treatment. But a new Yale-led study published in the Journal of the American Geriatrics Society suggests that overall health, function, and medical conditions may be more important than age alone when physicians and patients consider percutaneous coronary intervention (PCI), a common treatment for chronic coronary disease in which a small tube called a stent is placed inside an artery to help keep it open.

Chronic coronary disease, where plaque builds up in the arteries that supply blood to the heart, is more common in older adults. However, these individuals are often left out of clinical trials on heart procedures, according to Zafer Akman, MD, resident physician in the Department of Internal Medicine at Yale School of Medicine and first author of the study.

“Most of the existing evidence about PCI outcomes comes either from trials that excluded older adults or from registries focused on acute coronary syndromes rather than chronic disease,” Akman says. The study, he says, was designed to provide real-world outcome data that could help clinicians and patients make more informed decisions.

In the study, the researchers used data from more than 176,000 adults who underwent PCI for chronic coronary disease between January 2016 and June 2022. Nearly 30% of participants were 75 or older.

At first, older adults appeared to have higher rates of complications. But they also had more health issues before the procedure. After researchers compared older and younger patients with similar health backgrounds, they found that older adults had similar outcomes to younger patients.

Older adults had a slightly lower risk of major adverse cardiovascular events, including serious heart-related problems. They also had similar risks of death and major bleeding compared with younger adults. However, they had a 40% higher risk of being hospitalized for a heart-related cause within one year.

“One of the more interesting findings was that adults aged 75 and older had a somewhat lower adjusted risk of major adverse cardiac events than younger patients,” says senior author Michael Nanna, MD, MHS, assistant professor of medicine (cardiovascular medicine). “At first glance, that seems counterintuitive.”

The researchers noted that this finding does not mean that older age protects patients from heart issues. Instead, it likely reflects how carefully doctors choose older adults for PCI.

“The patients who ultimately undergo the procedure are often healthier and more likely to benefit than the broader population of older adults with chronic coronary disease,” Nanna says.

The study could not fully measure some factors that matter to many older adults, including memory and thinking skills, physical function, social support, symptoms, and quality of life. Akman says clinicians should consider those factors, along with each patient’s goals, when considering treatment options.

“An 80-year-old who is functionally independent and symptomatic despite medical therapy may be an excellent PCI candidate,” Akman says. “A 72-year-old who is frail with multiple comorbidities may not be.”

Ultimately, the goal is to better understand which patients benefit most from a procedure and what “benefit” means from the patient’s perspective, Nanna adds.

“For many older adults, success is not simply living longer,” he says. “It is remaining independent, maintaining function, and continuing to do the things that matter most to them.”

Cardiovascular Medicine, one of 10 sections in the Yale Department of Internal Medicine, is dedicated to improving cardiovascular health by advancing groundbreaking research, training the next generation of experts in cardiology, and delivering world-class patient care to people with a range of cardiovascular issues. To learn more, visit Cardiovascular Medicine.