Long-Term Clinical Outcomes of Medical Therapy for Coronary Chronic Total Occlusions in Elderly Patients (≥75 Years)

Abstract

Background: Limited data are available on the clinical outcomes of medical therapy (MT) compared with revascularization in elderly patients with coronary chronic total occlusion (CTO). Methods and Results:Between March 2003 and February 2012, we retrospectively analyzed 311 patients aged ≥75 years in the Samsung Medical Center CTO registry. Among these, 153 patients were treated with MT and 158 patients with revascularization by intervention or surgery. Inverse probability of treatment weighting (IPTW) and propensity score-matching were performed. The primary outcome was cardiac death during follow-up. Median followup duration was 34 (interquartile range: 15-58) months. Overall, patients in the MT group were high-risk subjects. Cardiac death of 30 patients (19.6%) occurred in the MT group vs. 17 patients (10.8%) in revascularization group (P=0.027). In the multivariate analysis, there was no significant difference between groups in the rate of cardiac death (hazard ratio [HR], 1.67; 95% confidence interval [CI], 0.86-3.24, P=0.13). After adjustment with IPTW, MT showed comparable risk of cardiac death with revascularization therapy (HR, 1.26; 95% CI, 0.71-2.21, P=0.43). In the propensity score-matched population, there was no significant difference in the rate of cardiac death between the MT and revascularization groups (HR, 1.52; 95% CI, 0.76-3.07, P=0.24). Conclusions:In the treatment of CTO in elderly patients, MT alone did not increase the risk of long-term cardiac death when compared with aggressive revascularization treatment. (Circ J 2015; 79: 1780 -1786

<p>Percutaneous Coronary Intervention in Elderly Patients with Coronary Chronic Total Occlusions: Current Evidence and Future Perspectives</p>

“…63 Chen et al enrolled 491 patients with ACS and aged ≥70 years, and found PCItreatment was associated with improved 1 and 3-year survival. 64 Lee et al retrospectively analyzed 311 CTO patients aged ≥75 years to compare the effectiveness of medical therapy with revascularization, and demonstrated that the incidence of cardiac death was comparable between groups (HR 1.67; 95% CI 0.86-3.24, = 0.13), 65 consistent with the findings of Guo and his colleagues. 66 Notable, among the 158 in the revascularization group, 43 patients underwent CABG and 24 patients had a failed PCI, and only 57% of patients had successful PCI.…”

Impact of revascularization versus medical therapy alone for chronic total occlusion management in older patients

“…There is only scarce evidence regarding the benefits of CTO revascularization in the older population. Lee et al studied a population of 311 older patients with CTO and showed similar rates of cardiac death at long‐term follow up regardless of MT or revascularization. This may have been due to a selection bias for CTO patients with fewer comorbidities, compared to our group of patients, yielding a lack of statistical power since only 47 cardiac events were observed.…”

“…[15][16][17][18] There is only scarce evidence regarding the benefits of CTO revascularization in the older population. Lee et al 19 In contrast to both of these studies, 19,20 we used broad inclusion criteria, overcoming the observed limitation of a too-healthy older cohort with a limited number of adverse events during follow-up. Our registry represents an unselected population encountered in daily clinical practice, and is sufficiently powered to assess adverse events following CTO revascularization compared to MT.…”

Current approaches for treatment of coronary chronic occlusions

“…Patients with a CTO and single vessel disease could benefit in an early stage from OMT, as PCI never showed a reduction in the risk of cardiac death and major adverse cardiovascular events (MACE) in patients with low APPROACH and SYNTAX scores [22,23]. Moreover, in elderly patients (≥75 years) and in those suffering from diabetes the advantages of CTO PCI are less evident [24,25].…”