Comparison of coronary revascularization strategies in older adults presenting with acute coronary syndromes

Abstract

Background The optimal coronary revascularization strategy to maximize the patient‐centered outcome of days alive and out of hospital (DAOH), in multimorbid older (≥65‐years) adults after an acute coronary syndrome (ACS) is incompletely understood. Methods Using Kaiser Permanente Northern California Health Plan databases, we identified 3871 patients ≥65‐years presenting with ACS between 1/1/2010–3/1/2018 who underwent coronary revascularization with either coronary artery bypass grafting (CABG, N = 1575) or multivessel percutaneous coronary intervention (PCI, N = 2296). Selection bias was accounted for through propensity score modeling techniques and inverse probability of treatment weighting. Cox proportional hazards models were fit to evaluate the association of revascularization type with outcomes. Primary Outcomes Absolute DAOH and the relative risk of achieving ≥90%DAOH during three time intervals. Secondary Outcomes All‐cause mortality, recurrent MI, stroke, rehospitalization, repeat revascularization, and dialysis initiation. Results CABG (compared to PCI) was associated with greater absolute number of DAOH, significant after the first year (mean difference at 1‐year: +5.8 days, 95% confidence interval [CI], −1.6 to 13 days; 3‐years: +56 days, 95%CI, +25 to +88 days; 5‐years: + 131 days, 95%CI, +57 to +205 days). The relative risk of achieving ≥90% DAOH significantly favored CABG after the first year (1‐year:1.02, 95%CI, 0.98–1.05; 3‐years:1.06, 95%CI 1.002–1.11, 5‐years:1.12, 95%CI, 1.03–1.22), and was related to lower incidences of all‐cause mortality, repeat revascularization, rehospitalization, incident dialysis, and nonfatal MI with CABG. Conclusions In older adults with multivessel or left main coronary artery disease who presented with ACS, CABG, after the first year, was associated with a greater absolute number of DAOH—a geriatric and patient‐centered outcome, compared to PCI. CABG patients also had a higher probability of achieving ≥90%DAOH—with lower all‐cause mortality, recurrent MI, repeat revascularization, new dialysis, and rehospitalization rates. Future randomized trials should study the impact of optimal revascularization strategies on the quality of life of older adults with multimorbidity.

Association between Controlling Nutritional Status Score and Severity of Coronary artery stenosis in elderly patients

“…Epidemiology studies have showed older age was cardiovascular disease (CVD) risk factor,especially for CAD [14]. One the one hand, with the increase of age, there were genomic instability cellular senescence and epigenetic changes in molecular hallmarks [15]. On the other hand, the comorbidities, such as hypertension, diabetes, may also predispose elderly patients to an increased risk of the development and process of atherosclerotic plaques [16].…”

The Impact of Geriatric Conditions in Elderly Patients with Coronary Heart Disease: A State-of-the-Art Review

“…Ongoing large studies will attempt to elucidate this crucial aspect [29,30]. Finally, in a selected group of patients (those with a low burden of comorbidities and no frail) presenting with ACS and having multivessel and/or left main coronary artery disease (CAD), coronary artery bypass grafting should be considered if percutaneous treatment is not feasible [31,32]. In any case, in all older patients with ACS undergoing invasive management (coronary angiogram ± PCI), certain precautions should be considered due to their higher likelihood and greater impact of developing adverse events.…”

Left Main Coronary Artery Disease—Current Management and Future Perspectives

“…Recent studies comparing the percutaneous approach with surgical treatment of CAD brought mixed results. The superiority of CABG was especially marked in patients with MVD, but not in LMCAD [ 63 , 64 , 65 ]. A substudy from the DELTA registry (Drug-Eluting stent for LefT main Artery) found no difference in the occurrence of the primary endpoint in octogenarians after CABG and PCI [ 66 ].…”