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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