Selection bias persists in complex high-risk PCIs

September 14, 2022

2 minute read


Disclosures: The authors report no relevant financial information.


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Data from a retrospective analysis show that there are significant differences in the types of complex high-risk PCI cases undertaken in centers in England and Wales, as well as differences in clinical outcomes between age groups.

“The nature of complex high-risk cases undertaken in the setting of elective PCI varies by age, with a lower prevalence of cardiometabolic risk factors in older patients,” Mamas A. Mamas, DPhil, MRCP, professor of cardiology with the Keele Cardiovascular Research Group at Keele University in Staffordshire, UK, told Healio. “In my view, this would suggest an element of selection bias, with only low-risk elderly patients being referred for PCI.”



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Mamas A.Mamas

In a retrospective study, Mamas and colleagues analyzed National Register data on complex high-risk PCI in patients with stable angina in England and Wales from 2006 to 2017, stratified into three age groups : less than 65 years old; 65 to 79 years old; and 80 years or older.

Of 424,290 elective PCI procedures, 33% were considered high-risk complex cases. Of these, 33.7% were carried out in adults under 65; 42.9% were performed in adults aged 65 to 79 and 23.4% were performed in adults aged 80 or over.

Among high-risk complex types, chronic total occlusion (49.2%), anterior CABG (30.4%), and severe vascular calcification (21.8%) were common in adults younger than 65 years . CAPs (42.9%), CTOs (32.9%) and severe vascular calcifications (27%) were common in adults aged 65-79; and anterior CAP (15.8%), severe vascular calcification (15.5%) and chronic renal failure (11.1%) were common in octogenarians.

Compared to adults younger than 65, people aged 65-79 were more likely to experience adverse events, including death (adjusted OR = 1.7; 95% CI, 1.3-2.3) , major bleeding (aOR = 1.3; 95% CI, 1.1-1.5) and MACCE (aOR = 1.2; 95% CI, 1-1.3). Octogenarians were more than twice as likely to experience mortality (aOR = 2.6; 95% CI, 1.9-3.6); and more likely to have major bleeds (aOR=1.4; 95% CI, 1.1-1.7) and MACCE (aOR=1.3; 95% CI, 1.1-1, 5) compared to younger adults.

“As our population ages, coronary calcification will increasingly become a common complex and high-risk factor in future PCI practice, and algorithms will need to be further refined when managing such cases in older populations, especially now that multiple options exist for calcium modification strategies,” Mamas told Healio. “High-risk complex PCI was common in patients of all age groups with significant left ventricular dysfunction. Given the results of the recent REVIVED-BCIS2 study, the role of elective PCI in this group of patients, especially those without symptoms, will need to be re-evaluated.

Mamas said consensus is needed on what is meant by “complex” PCI, as there is no uniformly accepted definition.

“We will need an analysis of longer-term outcomes for these patients, with a particular focus on the choice and duration of antiplatelets in these patient groups,” Mamas said.

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For more information:

Mamas A. Mamas, DPhil, MRCP, can be contacted at [email protected]; Twitter: @mmamas1973.

Martin E. Berry