Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide and its prevalence increases with advancing age. Management of acute coronary syndrome (ACS) in the very elderly patient is challenging, quiet often leading to unfavorable outcome as this group is less likely to receive standard guideline directed therapy due to multiple reasons like atypical presentations, delay in recognition, more complex CAD, frailty, cognitive impairment, multiple co-morbidities etc. They are underrepresented in clinical trials comparing management strategies in acute coronary syndrome.

This retrospective cohort study was aimed to evaluate the mid to long term outcome of treatment strategies in octogenarians presenting with acute coronary syndrome.Study was done by retrospective analysis of Electronic Medical Records (Cerner) of octogenarians admitted to our hospital between the year 2014 and 2017 with a primary diagnosis of acute coronary syndrome. Octogenarians were treated either by PCI or conservatively (non-PCI) according to the institutional protocol and based on patient’s clinical status. They were followed for further events with a mean follow up of 3.5± 2.2 years (1month to93months). Mid to long term outcome in both groups were analyzed and compared. Rate of re-hospitalization during this period was also compared.Data of 170 octogenarians admitted with ACS during this period were selected and analyzed for the study. Of these, 52 patients (30.6%) had undergone Percutaneous Coronary Intervention (PCI) and 114 patients (67%) were treated conservatively. 4 patient (2.4%) had undergone CABG, but they were excluded from the study as the number was small. Patients treated conservatively were comparatively older than PCI group (86.1±6.1 vs 83.6±4.6years; p=0.0106). No significant difference in gender ratio between the two groups (49.1% female in conservative group and 55.8% female in PCI group; p=0.4245). Majority of the patients presented with non-ST elevation myocardial infarction (97.4% in conservative; 71.2% in PCI).

In-hospital (17.5% vs 11.5%; p value0.3248) and 6-month (21.9% vs 13.5%; p=0.2045) mortality was numerically high in conservative group but it was not statistically significant. One-year all-cause mortality was significantly higher in conservative group than in PCI group (34.9%vs. 15.3%; p=0.0072). Subsequently the survival curve started diverging with significantly higher mortality in conservative group. During the mid to long term follow up for 3.5±2.2 years (1 to 93 months) total mortality was 71.1% in conservative group and42.3% in PCI group (p=0.0004). Most deaths were noncardiac in both groups (54.3% vs. 68.2%; p=0.2516). Combination of infection, sepsis and AKI were the most important cause of death in both groups (54.8% vs.50%; p=0.6938).There was significant difference in the average number of rehospitalizations per patient during the follow up period between conservative vs. PCI group (6.1 vs.3 per patient; p<0.0001). No significant difference in rehospitalization due to cardiac cause between two groups. Non-cardiac rehospitalization was high in conservative group(p=0.0484).Past coronary revascularization (35.1%in conservative vs. 19.2% in PCI; p=0.0389), CKD (68.5%vs. 28.8%; p=0.0001), anemia (28.4% vs 9.6%; p=0.0097), bleeding (12.3% vs 1.9%; p=0.0307), AF (28.9%vs 15.4%; p=0.0621), moderate or AS (13.2%vs 3.8%; p=0.0649) were higher in conservative group, which were statistically significant. In conservative group, 13.2% patients were bedridden/demented,8.8% were PEG fed and 2.6% were tracheostomy ventilated. Other baseline variables were similar and comparable between conservative and PCI groups (DM43.3% vs. 51.7%, p=0.3003; HTN 70.2%vs.83.3%, p=0.0629; CVD 61.4% vs. 50%, p=0.1690). Acute Kidney Injury was more prevalent in PCI group (26.7% vs.16.3%, p=0.1105), possibly related to contrast induced nephropathy. PCI showed more new bleeding complications (15.4%) and anemia (15% vs. 13.5%; p=0.7907) compared to conservative but were not statistically significant.

This retrospective cohort study shows that invasive strategy is safe and technically feasible treatment option in selected octogenarians which resulted in significant beneficial effects on long-term mortality. Patients in conservative group were older with more co-morbidities; this could probably explain the higher mortality in non-PCI group though it did not reflect in early mortality which was comparable. Besides, the mid-long term survival difference was markedly significant which was in favor of percutaneous coronary intervention. We conclude that percutaneous coronary intervention is a safe and effective treatment option for acute coronary syndrome in octogenarians and appears superior to conservative strategy resulting in improved survival and reduced early rehospitalizations.