| According to "China Aging Development Report (2013)" released by the Ministry of Civil Affairs and the National Statistics Office on Aging. By the end of 2012, the national population aged 60 and older has reached 194 million, accounting 14.3% of the total population; aged 65 and older has reached 118.8 million. The average annual increase of about 10 million elderly population, is expected to break 300 million in 2025. Older person combined with chronic increase is also increasing.In 2012, it reached 97 million, and it has been expected to exceed 100 million by 2013. Coronary atherosclerotic heart disease is a major threat for deathand disabilities to global human health.lt occursmore in the elderly population, and ranks in the top three chronic diseases. Our epidemiological data shows that coronary heart disease mortality for urban residents in 2011 was 95.97/100,000, and for rural residents was 75.72/100,000. From 2002 to 2011 the mortality rate of coronary heart disease and acute myocardial infarction is growing. The mortality rate of acute myocardial infarction increases with age, with age of 40 shows as a dividing line, then it has risen significantly. In 2011, the mortality rate for patients≥75 years old with acute myocardial infarction was 3,660.14/100,000. There is so muchmortality riskin elderly patients, and so much medical burden, so they need to be focused.Part 1ST-segment elevation myocardial infarction (STEMI) is the critical illness and acute presentation of coronary heart disease. Without timely treatment, it can easily cause a large area of myocardial infarction, a variety of clinical complications and even death. Current clinical guidelines recommend that STEMI patients should undergo percutaneous coronary intervention (PCI) therapy (IA level), but the clinical evidence are mostly from the younger patients (<65 years). For elderly patients with STEMI, there is still lack of clinical evidence regarding to the effectiveness, safety and feasibility of primary PCI. Therefore, this part of the study will examine the clinical effect of primary PCI in elderly patients.The use of a national multi-center registration (The Twelfth National Science and Technology Support Program:The treatment of cardiovascular disease, the key technology platform, project number:Registration 2011BAI11B02, Chinese Acute Myocardial Infarction Registry, CAMI Registry) It included a total of 19,345 peopleSTEMI patients. There are 5881 patients<55 years (non-aged group),5658 patients with 55-64 years old (moderate aged group),4614 patients with 65-74 years of age (advanced aged group), and 3192 patients≥75 years (very aged group). In-hospital mortality rates were 2.7%,4.0%,8.8%, and 15.9%(P<0.001). Patients who underwent emergency PCI treatment in each age groups were 49.1%,46.8%,40.5%, and 32.2% (P<0.001). The PCI-induced complications was similar between different age groups (3.5%,3.1%,3.9% and 4.6%,?=0.213). The mortality rates of patients who underwent emergency PCI were 1.4%,1.8%,2.5%, and 5.7%(P<0.001), which were greatly lower than the thrombolysis and not treated group. After adjustment for baseline confounders, the in-hospital mortality risk was 1.5 times of the advanced group, and 2.3 times of the very aged group compared with the moderate aged group. Other factors for predicting in-hospital mortality include:gender, chronic renal failure, Killip classification, heart rate, diastolic blood pressure, hospital level, antiplatelet agents, low molecular weight heparin, (3-blockers, and in-hospital use of statin.Conclusion:Primary PCI treatment is effective and safe for elderly STEMI patients. It is recommended to routinely select primary PCI in elderly patients.Part 2Elective PCI can treat the coronary stenosis, and improve the quality of life. But the elderly are more often associated with coronary complications and cardiovascular risk factors. So the adverse cardiovascular events after PCI, such as cardiogenic death, myocardial infarction, and ischemia driven revascularization. There is still lack of evidence for elderly patients if elective PCI treatment is safe and effective. Therefore, this part of the study will show the short and medium-term prognosis of elderly patients undergoing elective PCI.A retrospective study included 21,306 patients in Fu Wai Hospital from June 1,2006 to 2011 April 30 day, who had elective PCI with stent implantation. It included 8,128 non-aged patients,7,205 moderate aged patients,4,873 advanced aged patients, and 1,100 very aged patients. Aged patients had more risk factors than the non-aged group. The very aged group had most cardiovascular factors. In-hospital major adverse cardiovascular events (MACE) rates were 1.2%,1.4%,1.7% and 3.0% for each age group (P<0.001).1-year cardiogenic mortality rates were 0.2%,0.2%,0.7%, and 1.4% (P<0.001). Moderate aged group and non-aged group had similar prognosis, but advanced aged group and very aged group had more adverse cardiovascular events. Each aged group had similar TIMI 3 flows after PCI (97.8%,97.9%,97.9%, and 98.0%, P=0.931), the PCI-related dissection and acute thrombus were also similar (P>0.05). Although the in-hospital TVR was slightly more in very aged group (0.3%), TVR at 1-year follow-up was simiar. Factors used to predict in-hospital MACE included: advanced age (≥75 years vs<55 years), severe bleeding, left main disease, triple-vessel disease, dissection, thrombosis, and implantation of≥4 stents. For predicting 1-year cardiogenic mortality included:advanced age (65-74 years vs<55 years, and≥75 years vs<55 years), severe bleeding, left main disease.Conclusion:For elderly patients with coronary heart disease, elective PCI is safe and effective. Presumably, more advesre events occurred in the advanced aged and very aged group were due to the accompanied severe stenosis, the risk factors and age itself.Part 3The peri-procedure bleeding was associated with adverse events for a short and long term. Aged patients are at high risk of bleeding. However, the effect of bleeding in aged patients is unclear. So this part of the study will explore and compare the association.between bleeding and MACE in non-aged and aged patients.A retrospective study was performed which included 21,306 patients undergoing elective PCI in Fu Wai Hospital from June 1,2006 to 2011 April 30. BARC≥3 level bleeding was consided as criteria for grouping.The bleeding event was higher in the aged patients (0.8% vs 0.5%, P=0.014), where it was 0.6% in the moderate aged group,0.9% in the advanced aged group, and 2.2% in the very aged group. In non-aged group, patients with bleeding had more female (20.5% vs 10.6%, P=0.047), and lower rate of TRA (65.9% vs 88.1%, P<0.001). In aged group, patients with bleeding had older age (67.71±7.5 vs 64.35±6.65, P<0.001), and more diaberes (34.5% vs 25.4%, P<0.001). Other cardiovascular risk factors were similar between patients in the bleeding and non-bleeding group (P all>0.05). The bleeding group also had less TRA than the non-bleeding group (59.1% vs 84.2%, P<0.001).In non-aged group, patients with bleeding had more in-hospital MACE (11.4% vs 1.1%, P<0.001), in-hospital death (2.3% vs 0.1%, P<0.001),1-year MACE (13.6% vs 3.0%, P<0.001), and similar rate of 1-year death (2.3% vs 0.3%, P=0.141). In aged group, bleeding patients had higher rates of in-hospital MACE (9.1% vs 2.1%, P<0.001),1-year MACE (10.9% vs 4.3%, P=0.001), in-hospital death (3.6% vs 0.1%, P<0.001) and 1 year death (5.5% vs 0.8%, P<0.001). BARC≥3 level bleeding was independent predictors of in-hospital MACE (OR:3.339,95% CI:1.538,7.251), and 1-year MACE (HR:2.239,95% CI:1.134,4.424) in aged patients. Access-related and non access site-related bleeding were both associated with worse outcomes, but non access site-related bleeding had much more influence.Conclusion:For aged patients with coronary heart disease, peri-PCI bleeding (BARC ^3 level) was associated with incresed in-hospital and 1-year adverse cardiovascular events. Access-related and non access site-related bleeding were both associated with worse outcomes, but non access site-related bleeding had more influence. Whether the association between bleeding and MACE is more close in younger patients compared to aged paitents needs to be clarified.Part 4Compared to the traditional transfemoral approach, transradial intervention can reduce complications related to the puncture site and puncture site bleeding. The latest research also suggests that interventional through radial artery compared to the femoral artery reduces the 30-day mortality in ACS patients. In aged patients, especially very aged patients, the risk of death increased after bleeding. Therefore, whether the use of transradial interventional in reducing the puncture site bleeding can decrease mortality worth exploring.This retrospective study included 1,098 very aged pateitns in Fu Wai Hospital from June 1,2006 to 2011 April 30 day.873 patients were in the radial group, and 225 patients were in the femoral group. After using propensity score matching analysis,151 pairs included in the analysis. In-hospital MACE (1.3% vs 6.6%, P=0.014) and 1-year MACE (6.0% vs 13.9%, P=0.019) were significantly lower in the transradial group than in the transfemoral group. Although the in-hospital death, target vessel revascularization and each sub-endpoint of 1-year MACE were less than in the transradial group than in the transfemoral group, but the difference did not reach statistical significance (P>0.05). The transradial group had less access site complications than in the transfemoral group (3.3% vs 9.9%, P=0.018), and less BARC≥3 level bleeding (1.3% vs 5.3%, P=0.046). At the same, the transradial group had shorted post-procedure stay (3 [2,5] days vs 4 [3,7] days, P=0.002)CONCLUSION:In very aged patients, compared with transfemoral approach, interventional through radial artery showed great efficacy and good safety, it is recommended that transradial approach should be the routine access in very aged patients.Population aging is not to be neglected. In China, with such a large population base, the burden of cardiovascular disease in aged patients is increasingly severe. PCI in aged patients showed great efficacy and good safety, it should be recommended in aged patients in certain cases. Taking age into account, it should be careful in selecting PCI in aged people, which should ultimately in improve the long-term prognosis.
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