Surgical Myocardial Revascularization versus Percutaneous Coronary Intervention with Drug-Eluting Stents in Octogenarian Patients
DOI:
https://doi.org/10.1532/HSF98.20111190Abstract
Objective: Our goal was to compare the clinical outcomes of octogenarian (or older) patients who are referred for either surgical or percutaneous coronary revascularization.
Methods: We retrospectively evaluated the outcomes of all patients 80 years of age who had undergone coronary artery bypass grafting (CABG) with an internal mammary artery or had undergone a percutaneous coronary intervention (PCI) with a sirolimus-eluting stent to the left anterior descending artery in our center between May 2002 and December 2006.
Results: Of the 301 patients, 120 underwent a PCI, and 181 underwent CABG. Surgical patients had higher rates of left main disease, triple-vessel disease, peripheral vascular disease, emergent procedures, and previous myocardial infarctions (39.7% versus 3.3% [P = .001], 76.1% versus 28.3% [P = .0001], 19.6% versus 7.5% [P = .004], 15.8% versus 2.5% [P = .0001], and 35.9% versus 25% [P = .04], respectively). CABG patients had a higher early mortality rate (9.9% versus 2.5%, P = .01). There were no differences in 1- and 4-year actuarial survival rates, with rates of 90% and 68%, respectively, for the PCI group and 85% and 71% for the CABG group (P = .85). The rates of actuarial freedom from major adverse cardiac events (MACEs) at 1 and 4 years were 83% and 75%, respectively, for the PCI group, and 86% and 78% for the CABG group (P = .33). The respective rates of freedom from reintervention were 87% and 83% for the PCI group, versus 99% and 97% for the CABG group (P < .001). The 4-year rate of freedom from recurring angina was 58% for the PCI group, versus 88% for CABG patients (P < .001). Revascularization strategy was not a predictor of adverse outcome in a multivariable analysis.
Conclusion: Octogenarian CABG patients were sicker and experienced a higher rate of early mortality. The 2 strategies had similar rates of late mortality and MACEs, with fewer reinterventions and recurring angina occurring following surgery.
References
Barat I, Andersen F, Damsgaard EMS. 2000. The consumption of drugs by 75-year-old individuals living in their own homes. Eur J Clin Pharmacol 56:501-9.nBaskett R, Buth K, Ghali W, et al. 2005. Outcomes in octogenarians undergoing coronary artery bypass grafting. Can Med Assoc J 172:1183-6.nBlackstone EH. Comparing apples and oranges. 2002. J Thorac Cardiovasc Surg 123:8-15.nCosta JR Jr, Sousa A, Moreira AC, et al. 2008. Drug-eluting stents in the elderly: long-term (> one year) clinical outcomes of octogenarians in the DESIRE (Drug-Eluting Stents in the REal World) registry. J Invasive Cardiol 20:404-10.nDacey LJ, Likosky DS, Ryan TJ Jr, et al, Northern New England Cardiovascular Disease Study Group. 2007. Long-term survival after surgery versus percutaneous intervention in octogenarians with multivessel coronary disease. Ann Thorac Surg 84:1904-11.nDangas G, Ellis SG, Shlofmitz R, et al, TAXUS-IV Investigators. 2005. Outcomes of paclitaxel-eluting stent implantation in patients with stenosis of the left anterior descending coronary artery. J Am Coll Cardiol 45:1186-92.nFeldman DN, Gade CL, Slotwiner AJ, et al. 2006. Comparison of outcomes of percutaneous coronary interventions in patients of three age groups (<60, 60 to 80, and >80 years) (from the New York State Angioplasty Registry). Am J Cardiol 98:1334-9.nGuyon P, Urban P, Lotan C, Wijns W, Gershlick A, Sousa E. 2004. The impact of sirolimus-eluting stent implantation in the elderly: a report from the e-Cypher Registry [abstract]. Circulation 110III:646.nHannan EL, Wu C, Smith CR, et al. 2007. Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization. Circulation 116:1145-52.nHassani SE, Wolfram RM, Kuchulakanti PK, et al. 2006. Percutaneous coronary intervention with drug-eluting stents in octogenarians: characteristics, clinical presentation, and outcomes. Catheter Cardiovasc Interv 68:36-43.nHeron MP, Hoyert DL, Xu J, Scott C, Tejada-Vera B. 2008. Centers for Disease Control and Prevention. National vital statistics report. Vol. 56, No. 16 (June 11, 2008). Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_16.pdf. Accessed June 6, 2012. http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_16.pdf'>http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_16.pdfnHolzhev DM, Jacobs S, Mochalski M, et al. 2007. Seven-year follow-up after minimally invasive direct coronary artery bypass: experience with more than 1300 patients. Ann Thorac Surg 83:108-14.nKing SB 3rd, Kosinski AS, Guyton RA, Lembo NJ, Weintraub WS. 2000. Eight-year mortality in the Emory Angioplasty versus Surgery Trial (EAST). J Am Coll Cardiol 35:1116-21.nLikosky DS, Dacey LJ, Baribeau YR, et al, Northern New England Cardiovascular Disease Study Group. 2008. Long-term survival of the very elderly undergoing coronary artery bypass grafting. Ann Thorac Surg 85:1233-7.nLoop FD, Lytle BW, Cosgrove DM. 1986. Influence of internal-mammary-artery-graft in 10-year survival and other cardiac events. N Engl J Med 314:1-6.nMcFadden EP, Stabile E, Regar E, et al. 2004. Late thrombosis in drugeluting coronary stents after discontinuation of antiplatelet therapy. Lancet 364:1519-21.nMorice MC, Serruys PW, Sousa JE, et al, for the RAVEL Study Group. 2002. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 346:1173-80.nPeterson ED, Alexander KP, Malenka DJ, et al, American Heart Association Chronic CAD Working Group. 2004. Multicenter experience in revascularization of very elderly patients. Am Heart J 148:486-92.nSawhney N, Moses JW, Leon MB, et al. 2004. Treatment of left anterior descending coronary artery disease with sirolimus-eluting stents. Circulation 110:374-9.nSerruys PW, Morice MC, Kappetein AP, et al, for the SYNTAX Investigators. 2009. Percutaneous coronary intervention versus coronaryartery bypass grafting for severe coronary artery disease. N Engl J Med 360:961-72.nSerruys PW, Unger F, Sousa JE, et al., for the Arterial Revascularization Therapies Study Group. 2001. Comparison of coronary artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med 344:1117-24.nSousa JE, Costa A, Abizaid AS, et al. 2001. Lack of neointimal proliferation after implantation of sirolimus-coated stents in human coronary arteries: a quantitative coronary angiography and three-dimensional intravascular ultrasound study. Circulation 103:192-5.n[UNDPI] United Nations Department of Public Information. 2002. Population ageing: facts and figures published by the United Nations Department of Public Information. DPI/2264. March 2002.nUrban P, Gershlick AH, Guagliumi G, et al, on behalf of the e-Cypher Investigators. 2006. Safety of coronary sirolimus-eluting stents in daily clinical practice one-year follow-up of the e-Cypher registry. Circulation 113:1434-41.nVirmani R, Farb A, Guagliumi G, Kolodgie FD. 2004. Drug-eluting stents: caution and concerns for long-term outcome. Coron Artery Dis 15:313-8.n
