Influence of age on the clinical outcomes of coronary revascularisation for the treatment of patients with multivessel de novo coronary artery lesions: sirolimus-eluting stent vs. coronary artery bypass surgery and bare metal stent, insight from the multicentre randomised Arterial Revascularisation Therapy Study Part I (ARTS-I) and Part II (ARTS-II)

Abstract

Aims: We sought to evaluate the prognostic impact of age on the procedural results and subsequent clinical outcomes in patients with multivessel disease (MVD) treated either by coronary artery bypass surgery (CABG) or by percutaneous coronary intervention (PCI) with or without drug eluting stents, based on data of the Arterial Revascularisation Therapies Study (ARTS) part I and part II. The potential influence of age in determining the most appropriate revascularisation strategy for patients with MVD is largely unknown. Methods and results: Three year clinical outcome of ARTS I patients randomised to PCI with bare metal stent (BMS) (n= 600) or CABG (n= 605), and matched patients treated by PCI with sirolimus-eluting stents (SES) in ARTS II (n= 607) were reviewed according to four age quartiles. Endpoints were measured in terms of major adverse cardiac and cerebrovascular events MACCE) during hospital stay and up to three years. The frequency of female, diabetes, hypertension, peripheral vascular disease, pulmonary disease, as well as lesion complexity increased with age. At three years, MACCE free survival was comparable between patients treated by CABG or SES PCI, regardless of age quartile. The incidence of MACCE was higher among ARTS I BMS treated patients in all but the second age quartile. This was primarily related to a higher need for repeat revascularisation among BMS treated patients. However, age, which emerged as a strong independent predictor of MACCE following CABG (p<0.005), was not predictive of adverse events following PCI. Conversely, diabetes was the strongest independent predictor of MACCE among PCI treated patients (p<0.02), but didn't affect three-year outcomes following CABG. Conclusions: Age seems to influence the CABG outcome in-hospital but not PCI. PCI-SES could offer lower immediate risk in patients with MVD and comparable long-term outcome as CABG especially in older patients. The worst outcome of PCI-BMS group is primarily related to the need for repeat revascularisation. Diabetes is the most important predictor of MACCE following PCI.

Impact of age on the prognostic value of left ventricular function in relation to procedural outcomes following percutaneous coronary intervention: Insights from the British cardiovascular intervention society

“…Previous studies have reported that LV dysfunction is an independent predictor of adverse mortality and MACE outcomes following PCI and we have observed a similar independent relationship between LV dysfunction and worsening MACE and mortality outcomes in our cohort, in all age groups studied. Older patients have a greater burden of co‐morbid conditions , are more likely to have multivessel disease and adverse lesion characteristics such as tortuosity and severe calcification and age itself is independently associated with worse MACE and mortality outcomes in patients undergoing PCI in some studies but not all and features strongly in risk stratification scores for mortality and MACE prediction in patients undergoing PCI .…”

Optimal revascularization for complex coronary artery disease

“…However, age, which emerged as a strong independent predictor of MACCE following CABG surgery (P <0.005), was not a predictor of adverse events following PCI. 100 Similarly, the SYNTAX score II algorithm also favours PCI for older patients. 109 Emerging evidence suggests that frailty is a better marker of biological age and more important than chrono logical age in determining the outcomes after PCI 116 or CABG.…”

“…98 Conversely, diabetes was an independent predictor of outcomes after PCI, but not in CABG surgery, in the Australasian Society of Cardiac and Thoracic Surgeons and the Melbourne Interventional Group registry, 99 and in a combined post-hoc analysis of the ARTS-I and ARTS-II studies. 100 Two dedicated trials have shown a clear advantage of CABG surgery in patients with diabetes. The BARI 2D trial investigators enrolled 2,368 patients with type 2 diabetes and CAD who underwent either prompt PCI or CABG surgery with intensive medical therapy, or intensive medical therapy alone.…”

Proposed Recommendations for Myocardial Revascularisation

“…In patients over the age of 75, life expectancy is sufficiently limited that the long-term prognostic benefits of CABG are not seen [7,33,34]. Therefore revascularisation should focus on the safe relief of symptoms.…”