CHICAGO — Percutaneous coronary intervention may not be the best revascularization option for all octogenarians with multivessel coronary artery disease, according to a large study that pitted the procedure against surgical bypass.
The study of nearly 1,700 patients, aged at least 80, found that although in-hospital mortality and short-term survival were better for percutaneous coronary intervention (PCI), survival from 6 months to 8 years was significantly higher among the patients who underwent coronary artery bypass grafting for either two- or three-vessel disease.
The data are from the Northern New England Cardiovascular Disease Study Group, anchored at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. The data were presented at the annual meeting of the Society of Thoracic Surgeons.
“For a long time we never told octogenarians that there was a survival advantage to surgery. The emphasis was on quality of life. I think what we've found is that these older patients actually live quite a long time after treatment. Median survival was 7.7 years, and for those who had bypass it exceeded 8 years,” said lead investigator Dr. Lawrence J. Dacey in an interview.
Over the study period, there were 514 deaths and 5,530 person-years of data. Of the 991 patients who underwent coronary artery bypass grafting (CABG), the in-hospital mortality rate was 6%, compared with 3% among the PCI group. Under further analysis, survival in the first 6 months was slightly better among the PCI cohort.
From 6 months post treatment out to 8 years, CABG patients showed a trend toward increased survival that was most pronounced for those with three-vessel disease. “However, among those who survived for 6 months beyond their procedures, there was a significant 28% adjusted reduced risk of death at 8 years if they had had CABG rather than PCI,” said the Dartmouth physician. Among patients with two-vessel disease, CABG conferred a highly significant 32% reduced risk of death.
For patients with three-vessel disease, there was a trend toward improved survival with CABG that may have fallen short of statistical significance because of the relatively few PCI patients with three-vessel disease, stated Dr. Dacey.
The study included patients aged 80–89 years with two-vessel disease (58%) and three-vessel disease (42%) but no left-main disease, undergoing a first, nonemergent revascularization during 1992–2001 in northern New England. CABG patients tended to be younger, more often male, and have more peripheral vascular disease and congestive heart failure, while PCI patients had more renal dysfunction and a larger number of recent myocardial infarctions.
There exists among physicians what Dr. Dacey called a “bias that patients in this older group are too fragile to undergo major surgery. On the contrary, they're pretty robust and can handle a lot, and in our study those with the biggest advantage from bypass were those who were sickest to begin with.
Previous studies have shown the effectiveness of revascularization in enhancing the quality of life in elderly patients by providing both improved functional status and relief from angina, Dr. Dacey said. “Quality of life is particularly important for this age group. Studies have shown that CABG is equal or superior to PCI in improving quality of life. Patients aged 80 and older with multivessel coronary disease must carefully consider the trade-off between the increased up-front risk of CABG in return for improved long-term survival. Not everybody is appropriate for CABG, but those who do want to go through it should be allowed the opportunity to do so.”
There were limitations of the seven-center study: It was not randomized, there were no data on subsequent revascularization, and both PCI and CABG are evolving and improving technically, Dr. Dacey said.