Three-Year Outcomes of Multivessel Revascularization in Very Elderly Acute Coronary Syndrome Patients

Department of Health Policy & Management, University of North Carolina at Chapel Hill, North Carolina, United States
The Annals of thoracic surgery (Impact Factor: 3.85). 06/2010; 89(6):1889-94; discussion 1894-5. DOI: 10.1016/j.athoracsur.2010.03.003
Source: PubMed


Comparative effectiveness of interventional treatment strategies for the very elderly with acute coronary syndrome remains poorly defined due to study exclusions. Interventions include percutaneous coronary intervention (PCI), usually with stents, or coronary artery bypass grafting (CABG). The elderly are frequently directed to PCI because of provider perceptions that PCI is at therapeutic equipoise with CABG and that CABG incurs increased risk. We evaluated long-term outcomes of CABG versus PCI in a cohort of very elderly Medicare beneficiaries presenting with acute coronary syndrome.
Using Medicare claims data, we analyzed outcomes of multivessel PCI or CABG treatment for a cohort of 10,141 beneficiaries age 85 and older diagnosed with acute coronary syndrome in 2003 and 2004. The cohort was followed for survival and composite outcomes (death, repeat revascularization, stroke, acute myocardial infarction) for three years. Logistic regressions controlled for patient demographics and comorbidities with propensity score adjustment for procedure selection.
Percutaneous coronary intervention showed early benefits of lesser morbidity and mortality, but CABG outcomes improved relative to PCI outcomes by three years (p < 0.01). At 36 months post-initial revascularization, 66.0% of CABG recipients survived (versus 62.7% of PCI recipients, p < 0.05) and 46.1% of CABG recipients were free from composite outcome (versus 38.7% of PCI recipients, p < 0.01).
In very elderly patients with ACS and multivessel CAD, CABG appears to offer an advantage over PCI of survival and freedom from composite endpoint at three years. Optimizing the benefit of CABG in very elderly patients requires absence of significant congestive heart failure, lung disease, and peripheral vascular disease.

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Available from: Joseph S Rossi, Jan 20, 2014
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    • "It is generally accepted that patients with single-vessel obstructive CAD are best treated with PCI; however, the optimum revascularization strategy in patients with multivessel CAD with a higher ischemia burden, greater risk of recurrent ischemic events, and higher mortality is a matter of ongoing debate.10) In a cohort of 10141 patients with multivessel CAD aged >85 years, PCI showed early benefits of lesser morbidity and mortality, but CABG outcomes were significantly better by 3 years (p<0.01).11) In meta-analyses of trials comparing PCI and CABG for coronary revascularization, CABG was found to have either similar7) or better12) mortality outcomes in elderly patients. "
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    ABSTRACT: With the increase in life expectancy, the proportion of very elderly people is increasing. Coronary artery disease (CAD) is an important cause of mortality and morbidity in this age group, for which myocardial revascularization is often indicated. Percutaneous coronary intervention (PCI) in the very elderly bears the inherent risks of complications and mortality, but the potential benefits may outweigh these risks. A number of observational studies, registries, and few randomized controlled trials have shown the safety and feasibility of PCI in octogenarians and nonagenarians. However, PCI is only rarely done in centenarians; so, the outcome of percutaneous coronary revascularization in this age group is largely unknown. PCI in a centenarian with complex CAD is described here; the patient presented with unstable angina despite optimum medical therapy, and surgery was declined. Good angiographic success was followed by non-cardiac complications, which were managed with a multidisciplinary approach.
    Korean Circulation Journal 03/2014; 44(2):113-7. DOI:10.4070/kcj.2014.44.2.113 · 0.75 Impact Factor
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    ABSTRACT: ObjectiveWith progressive aging of population in developing nations, cardiac surgeons increasingly face elderly patients. These patients are usually symptomatic, yet at high risk for intervention. This study aims to review our experience in elderly Indian patients. MethodsWe reviewed the records of 128 elderly patients (mean age 74.6years; range 70–84) operated at our institution from 2005 to 2009. Postoperatively, patients were followed-up in the out-patient-department. ResultsSurgery was performed on 10 as an emergency and 41 on an urgent (on the day of referral or the following day) basis. Mean left ventricular ejection fraction was 44% ± 9.5. Early mortality (during current admission or within 30days of discharge from the hospital) was 12 (9.3%). Mean New York Heart Association functional class was improved from 3.0 ± 0.8 preoperatively to 1.5 ± 0.7 postoperatively. Median Intensive Care Unit and in-hospital stay was 4days (range 1–17) and 12days (range 4–37), respectively. Postoperative complications included pneumonia (6.3%), stroke (5.5%), reoperation for bleeding (4.6%) and intra-aortic balloon pump requirement (4.6%). Emergency surgery was significantly associated (P < 0.05) with an increased risk of early mortality- operative procedure and cardiopulmonary bypass time were not. ConclusionWe conclude that cardiac surgery can be performed in elderly population with an acceptable early mortality. Postoperatively, patients attain an improved quality of life. Operative procedures and cardiopulmonary bypass times are not risk factors for increased mortality. Emergency surgery in this group of patients is less rewarding. KeywordsCardiac–Surgery–Coronary artery bypass grafting
    Indian Journal of Thoracic and Cardiovascular Surgery 01/2011; 27(1):15-19. DOI:10.1007/s12055-010-0076-y
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    ABSTRACT: With the increased global burden of an aging population manifesting cardiovascular disease, the decision process for use of coronary revascularization options in older adults has gained attention. Assessment of physiologic status has greater bearing than chronologic age; items that have proven of particular merit in evaluating comorbidities as they relate to treatment prognosis for both PCI and CABG in older adults include EuroSCORE and frailty scoring. Evaluation of neurocognitive function can uncover the presence and severity of all-cause dementia, which may be missed in simple medical history interaction. These data have significance when considering aggressive coronary artery disease treatments in this population for symptomatic and/or survival benefit, particularly when high priority is placed on quality of life and independent living post-treatment. Recovery after procedural intervention is slower and with increased morbidity in older adults. Older adults tend to have more complex coronary artery disease; for some, the risk/benefit of revascularization may be prohibitive. Proper selection by the cardiac team for appropriateness of treatment options for each patient’s circumstances can result in excellent percutaneous coronary intervention and coronary artery bypass graft revascularization outcomes, even in the older adult. KeywordsCAD–Elderly–Frailty–Comorbidity–Risk Scores–PCI–CABG
    Current Cardiovascular Risk Reports 10/2011; 5(5):422-431. DOI:10.1007/s12170-011-0195-z
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