Survival after Coronary Revascularization in the Elderly
July 1, 2002 3 minutes read
Survival after Coronary Revascularization in the Elderly
The Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) study from Alberta, Canada, is derived from a registry that analyzed all patients undergoing cardiac catheterization in Alberta Province between 1995 and 1998. This cohort consists of > 20,000 individuals with ischemic heart disease. The analysis was focused on an age-related survival, comparing CABG, PCI, and medical therapy in patients in 3 age categories: < 70, 70-79, and > 80 years of age. A propensity analysis was carried out to assess the likelihood of a patient undergoing a revascularization procedure. The entire cohort was 21,573 patients; the large majority (15,392) were younger than 70; 933 were older than 80 years of age and 5198 were 70-80. Although the older patients had more cerebral and peripheral vascular disease, hypertension, and diabetes, and also had more urgent indications for catheterization; proportionally fewer elderly patients underwent CABG. The major indication for revascularization in the oldest cohort was unstable angina and severe CAD.
Results: Four-year survival rates for the youngest age group was similar for all treatments. The data demonstrate an increasing absolute survival advantage for those undergoing revascularization with increasing age. Four-year crude survival rates for individuals < 70 were > 92% for all treatment strategies; for individuals 70-79, CABG and PCI resulted in 86% survival vs. 82% for medical therapy; and in patients older than 80, survival rates were 83% and 77% for CABG and PCI, respectively, and 66% for medical therapy, P £ 0.0001. The adjusted 4-year survival rates were slightly worse for medical therapy in patients < 70. In the older age groups, CABG and PCI survival rates were 87 and 84% (age, 70-79) and 79% with medical therapy; in those older than 80, survival was 77% and 72%, respectively, for revascularization and 60% for medical therapy. The largest absolute risk reduction was seen in the eldest patients who underwent CABG or PCI. Graham and associates discuss the literature dealing with octogenarians, where there are little data comparing the 3 treatment approaches. They state that "an unexpected finding was the statistically significant difference in outcomes between the PCI and CABG groups," with an approximately 5% 4-year survival difference favoring CABG over PCI, with both being substantially better than medical therapy. The TIME trial and an analysis of the CASS Registry also found a long-term survival benefit with revascularization in older patients who were at the highest risk. Medical treatment of the elderly resulted in poor outcomes in the APPROACH study with a 15% yearly mortality. These individuals had lower ejection fractions and more congestive heart failure and azotemia than the CABG, but not PCI, cohorts. Graham et al point out that this is an observational report and that "unmeasured factors" may be responsible for selection bias in the surgical group. The propensity analysis indicates that the data are "robust and consistent across groups of patients with different probabilities of selection for revascularization." They conclude that recent randomized trial data as well as their findings "should be sufficiently compelling evidence to support a shift towards an aggressive treatment strategy in subsequent elderly patients." (Graham M, et al. Circulation. 2002;105:2378-2384.)
Comment by Jonathan Abrams, MD
These are impressive data, although clearly not randomized. At the very least, it indicates that relatively healthy elderly individuals, even older than age 75 or 80, who have advanced and symptomatic coronary disease should strongly be considered for revascularization. The choice of procedure is unclear but APPROACH would appear to favor bypass surgery over multivessel angioplasty. There may be confounding issues in patient selection in an elderly individual who is likely to have a good outcome after surgery vs. PCI. The conclusion that "age along should not be a deterrent to performing" PCI or CABG is in keeping with other data and is a credit to the outstanding results of cardiac surgeons and interventional cardiologists.
Dr. Abrams is Professor of Medicine, Division of Cardiology, University of New Mexico, Albuquerque.
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