Original Research
Cardiology 2014;129:46–54 Received: August 12, 2013
DOI: 10.1159/000360603
A Systematic Review on the Quality
of Life Benefits after Percutaneous
Coronary Intervention in the Elderly
Leonard Shan a Akshat Saxena b Ross McMahon b
a
Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Vic., and b Cardiology
Unit, South Eastern Sydney and Illawarra Health Network, Wollongong, N.S.W., Australia
For editorial comment see p. 44
Key Words
Percutaneous coronary intervention · Coronary angioplasty ·
Elderly · Quality of life
Abstract
Aims: Percutaneous coronary intervention (PCI) is being in-
creasingly performed on elderly patients with acceptable
peri-procedural outcomes and long-term survival. We aim
to systematically review the health-related quality of life
(HRQOL) following PCI in the elderly which is an important
measure of procedural success. Methods: A systematic re-
view of clinical studies before September 2012 was per-
formed to identify HRQOL in the elderly after PCI. Strict inclu-
sion and exclusion criteria were applied. Quality appraisal of
each study was also performed using pre-defined criteria.
HRQOL results were synthesised through a narrative review
with full tabulation of results of all included studies. Results:
Elderly patients have significant improvements in cardiovas-
cular well-being. Early HRQOL appears improved from base-
line, but recovery in physical health may be slower than in
younger patients. HRQOL is comparable to an age-matched
general population and younger patients undergoing PCI.
Conservative management is not able to offer the same
© 2014 S. Karger AG, Basel
0008–6312/14/1291–0046$39.50/0
E-Mail karger@karger.com
www.karger.com/crd
Accepted after revision: February 12, 2014
Published online: August 5, 2014
HRQOL benefits. Coronary artery bypass graft surgery may
be superior to PCI in the very elderly. Significant hetero-
geneity and bias exists. Lack of appropriate data precluded
meta-analysis. Conclusion: HRQOL after PCI in the elderly
can improve for at least 1 year across a broad range of health
domains, and is comparable to an age-matched general
population and younger patients undergoing PCI. Given a
limited number of articles and patients included, more pro-
spective studies are needed to better identify the benefits
for elderly patients. © 2014 S. Karger AG, Basel
Introduction
Rationale
The world’s population is ageing rapidly. According to
the United Nations Population Division, the proportion
of people over 60 years old is projected to double from 11
to 22% by 2050 within developed countries [1]. The num-
ber of very elderly people over 80 years old is projected to
increase by a factor of 26 compared to a factor of 10 and
3.7 for those over 60 years and the total world population,
respectively [1]. In association with the ageing popula-
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Akshat Saxena
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tion, the incidence of coronary artery disease (CAD) and
subsequent myocardial ischaemia or infarction is also ris-
ing. It is the world’s most common cause of death and
significant burden of disease [2, 3]. A quarter of people
older than 75 years will have symptoms of CAD and the
majority will have impaired health-related quality of life
(HRQOL) or function [4–7]. This constitutes a major
public health problem.
Currently, the most common method of performing
myocardial revascularisation in CAD patients is by per-
cutaneous coronary intervention (PCI) [4]. PCI is being
increasingly performed in elderly patients [8–11]. Re-
ported peri-procedural mortality is 6.9–7.6% in elective
procedures [9, 12–14], but can be as high as 15.5–17.2%
in octogenarians with acute ST elevated myocardial in-
farcts [15, 16]. Patients’ subjective perception of their
HRQOL is equally as important as objective end-points
such as mortality in considering PCI [4, 17, 18]. HRQOL
has become an increasingly important outcome measure
in patients with cardiovascular disease and is frequently
used in evaluating benefits of treatment [19]. Studies have
shown good HRQOL outcomes after PCI [4, 20, 21], but
results in elderly patients remain limited [8, 12, 22–30].
Considering that life expectancy is 17.1 years at the age of
65 and 8.2 years at the age of 80 [1], there is a significant
opportunity for elderly patients to improve their HRQOL
if they are offered intervention.
This systematic review aims to: (i) summarise the lit-
erature and clarify strengths and weaknesses of current
evidence on HRQOL after PCI in the elderly, (ii) demon-
strate whether there is a HRQOL benefit in elderly pa-
tients after PCI and whether it is enough to justify the
procedure, (iii) explore factors which may lead to a worse
HRQOL, and (iv) identify areas of need for future re-
search.
Methods
The structure of this systematic review followed previously rec-
ommended guidelines [31] and was written in accordance with the
PRISMA checklist for systematic reviews [32].
Definition and Measurement of HRQOL
The World Health Organisation (WHO) has defined health as
being ‘not only the absence of disease and infirmity but also the
presence of physical, mental, and social well-being’ [33]. HRQOL
encapsulates an individual’s physical, emotional and psychological
health as well as social and functional status [34, 35]. Because
HRQOL is not a tangible entity, a standardised method of mea-
surement is required which is reliable, valid, responsive, sensitive,
and covers all health domains [34].
Quality of Life after PCI in Elderly
In cardiovascular disease, disease-specific QOL measures such
as the Seattle Angina Questionnaire (SAQ) [36] aim to accurately
reflect a patient’s experience of a specific illness or its treatment.
Generic HRQOL instruments are required to facilitate a holistic
assessment. Well-recognised generic HRQOL instruments in car-
diovascular disease include Medical Outcomes Survey Short-
Form 36 (SF-36) [37–40], EuroQOL [41] and Medical Outcomes
Survey Short-Form 12 (SF-12) [42, 43].
Eligibility Criteria
Study characteristics were: (i) elderly patients defined as great-
er than 70 years old, (ii) PCI as a primary intervention, (iii) com-
parisons made with pre-operative status, younger patients under-
going similar procedures or an age-matched general population,
(iv) comparison with conservative management or coronary artery
bypass graft surgery (CABG), (v) HRQOL methods of assessment
and results reported, and (vi) retrospective and prospective inves-
tigative studies. Report characteristics were: (i) publication date
before and including September 2012, (ii) fully published status,
and (iii) English language.
Literature Search and Information Sources
A literature search was conducted using MeSH keyword search
via PubMed. Strict inclusion criteria for study characteristics were
applied as described. On 7/9/2012 a search was conducted as de-
scribed in figure 1. A manual search of EMBASE, DISCOVERY
and MEDLINE as well as bibliographies of included studies was
also conducted to identify any other studies not covered by the
initial search.
Study Selection
Two reviewers screened titles and abstracts after both MeSH
keyword and manual searches. Studies were excluded if they did
not meet eligibility criteria. If the information required to deter-
mine eligibility was not in the abstract, a second pass was run after
data extraction.
Data Items and Collection Process
Data extraction was then performed in two phases by two re-
viewers using standardised pilot forms. The first phase involved
assessment of study quality (table  1) and the second phase col-
lected results of the studies reviewed (table 2). All data items were
pre-determined and specified in these tables.
Assessment of Risk of Bias in Individual Studies
Risk of bias was assessed mainly by evaluating: (i) study design,
(ii) the number of patients, (iii) the use of a generic HRQOL instru-
ment, and (vi) questionnaire response rates.
Results
After careful systematic selection, 10 studies were in-
cluded in this systematic review [8, 12, 22, 24–30]. Full
details and results of reviewed articles are provided in ta-
bles 1 and 2.
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Search algorithm
7/9/2012
MeSH keywords
‘Angioplasty, Transluminal, Percutaneous
Coronary’ AND ‘Quality of Life’ AND ‘Elderly’
Limiters
AND Language ‘English’
153 articles identified
147 articles excluded
6 articles [12, 22, 26–28, 30]
Studies not relevant for present review, elderly
not >70 years old, reviews, inadequate methods or
results of HRQOL assessment
Plus manual search
(EMBASE, DISCOVERY, MEDLINE)
4 articles [8, 24, 25, 29]
10 articles included [8, 12, 22, 24–30]
Being appropriate for this systematic review due to
relevancy to this topic and scientific accuracy of the
reported results
Fig. 1. Search algorithm.
Cardiac Specific QOL Measures
There were significant improvements from baseline to
1 year reported across all SAQ domains [8, 12, 29]. El-
derly patients achieved similar SAQ scores to younger pa-
tients undergoing the same procedures [29], but may ex-
perience a slower physical recovery [27]. The very elderly
over 80 years of age may have greater SAQ improvements
after CABG compared to PCI [8].
48 Cardiology 2014;129:46–54
DOI: 10.1159/000360603
Graham et al. [8] were the only authors to report long-
term results later than 1 year. They showed SAQ im-
provements persisted to 3 years.
Generic Health-Related Quality of Life Instruments
SF-36 scores were superior after PCI compared to be-
fore [12, 25, 27]. In particular, there is good recovery of
physical health domains [12, 24, 25]. The impact on men-
tal health domains is less pronounced [25]. Elderly pa-
tients who underwent PCI had higher SF-36 scores across
all eight domains compared to those who had conserva-
tive treatment [25]. In patients over 75 years of age, PCI
may be superior to CABG for physical health, but mental
health was similar [28].
Two studies show equivalent or superior HRQOL on
both SF-36 and EuroQOL compared to an age-matched
population [8, 30]. This benefit is marked even for nona-
genarians [22]. Agarwal et al. [12] contradict these find-
ings demonstrating that at both 6 and 12 months after
PCI, all SF-36 domains were worse compared to an age-
matched UK population.
Multiple studies report SF-36 scores equivalent to or
better in elderly patients compared to younger controls
[12, 24, 27, 29]. Along with a slower physical recovery on
SAQ compared to younger patients, the physical compo-
nent score may also be worse [28]. The mental compo-
nent score and individual domains were not different
[28].
Shah et al. [30] were the only authors that reported
HRQOL later than 1 year post-procedure. Though results
were positive, mean follow-up was only 1.3 years.
Some studies utilised self-constructed QOL measures.
Little et al. [26] report good recovery of health and satis-
faction with life along with self-perceived QOL. Almost
all patients had no residual chest pain and 95% believed
that had an improved HRQOL. This resulted in 92% pa-
tients returning to their former activity levels [26].
Factors Affecting Health-Related Quality of Life
There is limited data on factors affecting HRQOL after
PCI in the elderly. Li et al. [25] report that the indepen-
dent predictors of better physical component score are
PCI, no previous revascularisation and age.
Discussion
Strength of Evidence and Bias
The strength of evidence was analysed systematically
in this review. Detailed results can be found in table 1.
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 Table 1. Quality appraisal

Author, year Defined as Study Methodological quality Precision

(study period) elderly, n design
validated HRQOL cardiac-specific elderly patient demographics follow-up method and follow-up range/CI/SE/SD
instrument measures HRQOL assessment consistency of results

Little [26] 118 R No No Males: 43%, location: USA Baseline: NR PR: 95% Follow-up: wide
1993 (own Smoking, diabetes, HTN, Chol, By telephone RR: 98% QOL: NR

Quality of Life after PCI in Elderly

(1986 – 1990) questions) multi-VD, all NR Repeat attempts: NR
Kähler [24] 34 P Yes No Males: 71%, location: Germany Baseline performed PR: 100% Follow-up: NR
1999 (SF-36) Smoking 9%, DM 24%, HTN 77%, Chol 53%, By telephone RR: NR QOL: moderate
(1996 – 1997) single VD 12%, multi-VD 88% Repeat attempts
Seto [29] 1,789 P Yes Yes Males: NR, location: USA Baseline performed PR: NR Follow-up: NR
2000 (SF-36) (SAQ) Smoking, diabetes, HTN, Chol, By mail RR: 80% QOL: moderate
(NR) multi-VD, all NR Repeat attempts: by
telephone
Graham [8] 137 R No Yes Males: 56.2%, location: Canada Baseline: NR PR: NR Follow-up: NR
2006 (SAQ) Smoking, diabetes 19.7%, HTN 50.4%, By mail or telephone RR: 77.7% QOL: wide
(1995 – 1998) Chol 29.9%, single or double VD 13%, triple Repeat attempts and
VD 20.3% reminders
Moore [27] 34 P Yes Yes Males: 65%, location: UK Baseline performed PR: NR% Follow-up: NR
2006 (SF-12) (SAQ) Smoking 65%, diabetes 15%, HTN 62%, Method: NR RR: 95% QOL: NR
(2001 – 2002) Chol 85%, multi-VD 24% Repeat attempts NR
Agarwal [12] 74 P Yes Yes Males location: UK Baseline performed PR: NR Follow-up: NR
2009 (SF-36) (SAQ) Smoking, diabetes, HTN, Method: NR RR: NR QOL: NR
(NR) Chol, multi-VD 37.8% Repeat attempts NR
Shah [30] 73 P Yes No Males: 38%, location: USA Baseline performed PR: 47% Follow-up: NR

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2009 (EuroQOL) Smoking 7%, diabetes 17%, HTN 85%, By telephone RR: 94% QOL: narrow
(2002 – 2007) Chol 43%, multi-VD 57% Repeat attempts NR
Chait [22] 173 R Yes No Males location: USA Baseline: NR PR: 54% Follow-up: NR
2011 (SF-36) Smoking 35%, diabetes 15%, HTN 86%, By telephone RR: 71% QOL: moderate
(2005 – 2009) Chol 51%, single or double VD NR Repeat attempts: NR
Rittger [28] 39 P Yes No Males: 49%, location: Germany Baseline NR PR: NR Follow-up: NR
2011 (SF-36) Smoking NR, diabetes 39%, HTN 80%, Method: NR RR: 75% QOL: moderate
(2004 – 2007) Chol 39%, triple VD 67% Repeat attempts
Li [25] 287 P Yes No Males: 37%, location: China Baseline performed PR: 100% Follow-up: NR
2012 (SF-36) Smoking 14%, diabetes 42%, HTN 75%, By telephone or RR: 81.5% QOL: moderate
(2006 – 2008) Chol 30%, multi-VD NR interview
Repeat attempts: NR

P = Prospective; R = retrospective; NR = not recorded; DM = diabetes mellitus; HTN = hypertension; Chol = cholesterol; VD = vessel disease; PR = participation rate; RR = response rate;
NA = not applicable; EuroQOL = EuroQOL EQ-5D and EQ-VAS questionnaire.

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Table 2. Results of studies reviewed

Author Defined as Elective/ Comparison Follow-up Mortality Results

(year) elderly; urgent group on interval
mean age (success rate) generic QOL

Little 80 years; NR NA 18.1± 4.6% CCS III/IV: NR (pre-PCI), 11% (post-PCI)

[26] 83 (80 – 91) (89%) 10.4 months On a 10-point scale, recovery of health was rated 8.9 ± 1.9, QOL at
(1993) 8.3 ± 2.0 and satisfaction with life at 8.0 ± 2.3. Life was prolonged in
95% of elderly patients; 97% had no chest pain; 95% had improved
QOL with 92% returning to former activities of daily living; 92%
were able to undertake travel and recreation; 66% lived at home
independently
Kähler 80 years; Elective Control group; 0 and 0% CCS III/IV: 50% (pre-PCI), NR (post-PCI)
[24] (83 ± 3) (88%) 62 ± 8 years 6 months Significant increase in RP (29 ± 8 vs. 61 ± 15) and BP (44 ± 16 vs. 71 ±
(1999) 22); improvement in RP more for octogenarians than control
group; no significant changes in the 6 other domains
Seto 70 years; NR Control group; 0, 6 and NR CCS III/IV: NR (pre- and post-PCI)
[29] [74 (70 – 89)] 57 (38 – 69) 12 months Elderly patients had significant improvements in PCS (36.0, 44.6,
(2000) years 45.0) and MCS (50.6, 54.9, 54.8) from baseline to 1 year; there were
substantial gains on SAQ PF, AF, DP domains; improvement in
HRQOL after PCI was not significantly associated with age;
proportion of elderly patients with PCS (51 vs. 58%), MCS (29 vs.
30%), PF (58 vs. 54%), AF (75 vs. 74%) and DP (75 vs. 69%)
improvements was not different compared to the younger cohort;
at 6 months and 1 year, 60% patients reported no angina
Please refer to original article for more detailed quantitative results.
Graham 80 years; Elective and Age-matched 1, 2 and 9.2% CCS III/IV: NR (pre-PCI), 11% (post-PCI)
[8] (82.1±NR) urgent general 3 years PCI confers superior 1-year crude SAQ scores compared to medical
(2006) (NR) population treatment in patients aged <70 and 70 – 79; for patients aged >80
Younger years, crude scores were significantly better for CABG; SAQ
patient dimensional scores at 1 year were better for PCI or CABG
cohort compared to medical treatment in all dimensions of SAQ; these
findings are similar at 3-year follow-up; risk-adjusted scores show
that all patient groups, in particular >80 years, derive significant
improvements in all SAQ domains; CABG patients have higher
scores than PCI patients in all dimensions except exertional
capacity
Please refer to original article for more detailed quantitative results.
Moore 70 years; Elective Pre- versus 0 and NR CCS III/IV: NR (pre- and post-PCI)
[27] (76.0 ± 5) (NR) post-PCI 12 months All dimensions of the SF-12 and SAQ questionnaires were superior
(2006) Younger at 1 year for all age groups except for TS (SAQ) which was not for
controls those aged 60 – 70 or >70 years; there was no significant difference
in score changes for PCS (p = 0.232), MCS (p = 0.605), AS (p =
0.068), AF (p = 0.104), TS (p = 0.277) and QOL domain (p = 0.137)
for all 3 age groups; PL domain was significantly different (p =
0.047), with less recovery observed in older patients
Please refer to original article for more detailed quantitative results.
Agarwal 80 years; NR Pre- versus 0, 6 and NR CCS III/IV: NR (pre- and post-PCI)
[12] (82.5 ± 2.3) post-PCI 12 months 40% had no angina at 6 months and 36% at 12 months; PCS (31.7
(2009) Age-matched vs. 47.0 vs. 46.2) and MCS (44.6 vs. 58.0 vs. 57.6), including RP (7.9
population vs. 33.8 vs. 38.7), BP (40.1 vs. 61.6 vs. 58.4) and RE (35.8 vs. 57.3 vs.
62.3) improved at 6 months; these gains persist to 12 months; the
other domains were similar; at both 6 and 12 months, all SF-36
domains were lower than the age-matched UK population; there
were significant improvements at 6 months for SAQ which were
sustained to 12 months (baseline vs. 6 months vs. 12 months): PL
(24.4 vs. 42.3 vs. 41.1), AS (50.0 vs. 72.4 vs. 66.3), AF (45.8 vs. 76.5
vs. 73.5), TS (74.3 vs. 83.7 vs. 83.7), DP (38.8 vs. 66.7 vs. 62.3).
Please refer to original article for more detailed quantitative results.
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Table 2 (continued)

Author Defined as Elective/ Comparison Follow-up Mortality Results

(year) elderly; urgent group on interval
mean age (success rate) generic QOL

Shah 85 years; NR Age-matched 492 days 32% CCS III/IV: NR (pre- and post-PCI)
[30] (88 ± 0.3) (94%) population Mean summary EQ-5D (0.78 ± 0.04 vs. 0.72 ± 0.01) and EQ-VAS
(2009) (70.5 ± 4.5 vs. 64.6 ± 1.4) index scores were similar to an age-
matched population; few patients had severe problems on EQ-5D:
mobility (6%), self-care (9%), usual activities (13%), pain/
discomfort (0%) and anxiety/depression (0%)
Chait 90 years; NR Age-matched NR 7.8% CCS III/IV: NR (pre- and post-PCI)
[22] 92 (90 – 101) (98%) population Nonagenarians achieved superior RP (p = 0.001), BP (p = 0.03), GH
(2011) (p = 0.004), VT (p = 0.001), SF (p = 0.049), RE (p = 0.002), MH
(p = 0.004), PCS (p = 0.044), MCS (p = 0.001) scores compared to
an age-matched general population; PF (p = 0.518) was not
statistically different
Please refer to original article for more detailed quantitative results.
Rittger 75 years; NR Younger 6 months 0% CCS III/IV: NR (pre-PCI), 11% (post-PCI)
[28] (81 ± 4) (100%) controls Elderly patients had a reduced PCS (38 ± 12 vs. 42 ± 12, p = 0.016)
(2011) compared to younger patients; MCS was not significantly different;
in patients aged >75 years, PCI may be superior to CABG for
physical health (38 ±12 vs. 33 ± 13), but mental health was similar
(49 ± 10 vs. 50 ± 10); there were also no differences in all the
individual domains (quantitative result: NR)
Li 80 years; NR Pre- versus Baseline and 0.3% CCS III/IV: NR (pre- and post-PCI)
[25] NR post PCI 6 months Patients treated with PCI had higher scores at 6 months in all 8
(2012) PCI versus domains than those with conservative treatment; after risk
non-PCI adjustment, elderly patients had significantly better PCS (40 ± 11 vs.
versus younger 30 ± 15, p = 0.02), PF (65 ± 21 vs. 45 ± 27, p = 0.01) and GH (63 ± 21
controls vs. 49 ± 23, p = 0.03) compared to conservative treatment; this effect
was not seen in younger patients; all other domains on SF-36 were
equivalent between PCI and conservative treatment; elderly
patients also derived the most gains on most domains after PCI;
independent predictors of better PCS at 6 months were PCI (OR =
1.79, CI = 1.10 – 2.92), no previous revascularisation (OR = 2.04,
CI = 1.01 – 4.15) and age per 10-year increase (OR = 1.27, CI =
1.02 – 1.57)
Please refer to original article for more detailed quantitative results.

P = prospective; R = retrospective; NR = not recorded; DM = diabetes mellitus; HTN = hypertension; Chol = cholesterol; VD = vessel disease; PR = par-
ticipation rate; RR = response rate; NA = not applicable; CCS = Canadian Cardiac Score; EuroQOL = EuroQOL EQ-5D and EQ-VAS questionnaire; PL =
physical limitation; AS = angina severity; AF = angina frequency; DP = disease perception or QOL; TS = treatment satisfaction; PF = physical functioning;
RP = role – physical; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; MH = mental health; RE = role – emotional; PCS = phys-
ical component summary score; MCS = mental component summary score; PCI = percutaneous coronary intervention.

Heterogeneity of primary outcomes and a small number
of studies prevented direct comparison of results or meta-
analyses.
The majority of studies were prospective which pro-
vided accurate HRQOL results at definitive time-points
[12, 24, 25, 27–29]. There were no randomised controlled
trials. Only three studies indicated if PCI was performed
electively or emergently [8, 24, 27]. All except two studies
[8, 26] used SF-36 [12, 22, 24, 25, 27–29] or EuroQOL [30]
instruments which reduces bias and ensures coverage of
the WHO’s QOL definition. Despite this, the number of
studies remains small and thereby limits the generalis-
ability of these results.
According to previous guidelines, a response rate of
>85% (loss to follow-up <15%) is considered ideal for
treatment-received analyses [31]. Seven studies included
in this review either did not reach this mark or did not
report response rates [8, 12, 22, 24, 25, 28, 29]. Question-
naires were administered by telephone in most studies [8,
22, 24–26, 30]. This is considered to be more reliable and
achieves greater response rates than self-administered
postal questionnaires [44]. The precision of HRQOL re-
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sults is reflected by the confidence interval, range or stan-
dard error of instrument scores. This information was
provided in most studies [8, 22, 24, 25, 28–30], but a nar-
row result was attained in only one [30].
The increasing elderly population will lead to progres-
sively increasing demand for intervention, especially in
this age group. There is significant bias in studies includ-
ed, but this systematic review summarises the best avail-
able evidence on HRQOL after PCI in the elderly.
Summary of Evidence and Interpretation
The main findings of the studies included for review
are that elderly patients have (i) better post-PCI HRQOL
compared to pre-PCI [8, 12, 25, 27, 29], (ii) better
HRQOL compared to patients who have conservative
treatment [25], (iii) better HRQOL compared to an age-
matched general population [8, 22, 30], and (iv) equiva-
lent or superior HRQOL compared younger patients
who underwent PCI [12, 24, 27, 29]. These benefits are
observed for at least 1 year. Functional status may also
be improved [12, 29]. Whereas there was abundant data
on HRQOL outcomes up to 1 year, evidence on late
HRQOL remains scarce. However, the caveat is that the
study quality is low and subsequently the potential for
significant bias should be accounted for in the interpre-
tation of the findings.
The ageing population and increasing life expectancy
of patients greater than 70 years of age to at least 15 years
will lead to continuing increases in CAD requiring PCI.
Whilst there are specific risks of performing PCI in el-
derly patients, this must be considered in relation to ben-
efits for HRQOL. Peri-procedural mortality rates appear
to be higher in elderly compared to younger patients, but
if they survive the procedure, their long-term survival and
HRQOL is acceptable [9–11]. The oldest patient groups
may benefit the most from PCI in their physical health
compared to younger patients [25]. Given the survival
and HRQOL benefits, it is important to avoid letting el-
derly patients become inadequately managed with con-
servative treatment where HRQOL is much worse than
with PCI [25]. Delay or exclusion from intervention based
solely on age may deny patients from receiving best prac-
tice care.
A recent meta-analysis demonstrated no difference in
30-day mortality and 1-year survival between PCI and
CABG for octogenarians [45]. For both PCI and CABG,
increasing age appears to be associated with an increased
risk of early mortality [12, 46]. However, in the very el-
52 Cardiology 2014;129:46–54
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derly, CABG appears to confer equivalent 5-year survival
as an age-matched healthy population. Furthermore,
HRQOL post-CABG is similar or better compared to PCI
[8, 28]. Data directly comparing HRQOL outcomes of
PCI to CABG in elderly patients remains scarce. PCI may
have a role as a bridging procedure prior to surgery in the
very elderly or those with multiple comorbidities.
Regardless of the method of revascularisation, the fo-
cus of treatment in elderly patients is no longer purely
about prolonging life, but also about improving the
HRQOL. Information about expected HRQOL allows
these patients to have realistic expectations on physical,
functional, emotional and mental welfare. This review
demonstrates that there is increasing evidence showing
worthwhile gains with regard to HRQOL after PCI in se-
lected elderly patients. Given that associated healthcare
costs of PCI also do not appear to be significantly greater
for elderly patients [24], healthcare providers should
more readily consider elderly patients for PCI.
Review Limitations
The key limitation of this review is the heterogeneity
of the included studies. In addition, only 10 studies fit
the eligibility criteria for inclusion in this review. These
studies also carry significant bias. However, this is the
only evidence to date and reflects the quality of available
data. This systematic review adds substantially to litera-
ture for elderly patients being considered for PCI and
builds on the conclusions of previous non-systematic
narrative reviews [23]. More large prospective trials are
required to identify long-term HRQOL after PCI in the
elderly.
Conclusion
HRQOL after PCI in the elderly can improve for at
least 1 year across a broad range of health domains, and
is comparable to an age-matched general population and
younger patients undergoing PCI. Data remains limited.
This systematic review should encourage doctors to eval-
uate potential PCI patients on the basis of their comor-
bidities rather than using age as a precluding factor. Stud-
ies are still limited and more are required in order to be
conclusive. In the absence of large randomised controlled
trials, this recommendation must be considered in con-
junction with clinical decision-making tailored to each
patient.
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