Three-year outcomes of multivessel revascularization in very elderly acute coronary syndrome patients

Abstract

Background: Comparative effectiveness of interventional treatment strategies for the very elderly with acute coronary syndrome remains poorly defined due to study exclusions. Interventions include percutaneous coronary intervention (PCI), usually with stents, or coronary artery bypass grafting (CABG). The elderly are frequently directed to PCI because of provider perceptions that PCI is at therapeutic equipoise with CABG and that CABG incurs increased risk. We evaluated long-term outcomes of CABG versus PCI in a cohort of very elderly Medicare beneficiaries presenting with acute coronary syndrome.

Methods: Using Medicare claims data, we analyzed outcomes of multivessel PCI or CABG treatment for a cohort of 10,141 beneficiaries age 85 and older diagnosed with acute coronary syndrome in 2003 and 2004. The cohort was followed for survival and composite outcomes (death, repeat revascularization, stroke, acute myocardial infarction) for three years. Logistic regressions controlled for patient demographics and comorbidities with propensity score adjustment for procedure selection.

Results: Percutaneous coronary intervention showed early benefits of lesser morbidity and mortality, but CABG outcomes improved relative to PCI outcomes by three years (p < 0.01). At 36 months post-initial revascularization, 66.0% of CABG recipients survived (versus 62.7% of PCI recipients, p < 0.05) and 46.1% of CABG recipients were free from composite outcome (versus 38.7% of PCI recipients, p < 0.01).

Conclusions: In very elderly patients with ACS and multivessel CAD, CABG appears to offer an advantage over PCI of survival and freedom from composite endpoint at three years. Optimizing the benefit of CABG in very elderly patients requires absence of significant congestive heart failure, lung disease, and peripheral vascular disease.

Fig 1

Diagram of cohort identification and exclusions. (ACS = acute coronary syndrome; CABG = coronary artery bypass graft; MedPAR = Medicare Provider Analysis and Review; PCI = percutaneous coronary intervention.)

Fig 2

Adjusted survival with confidence interval for persons age 85 and older. (CABG = coronary artery bypass graft; PCI = percutaneous coronary intervention; p < 0.05.)

Fig 3

Adjusted freedom from composite outcome (composite of death, repeat revascularization, stroke and acute myocardial infarction) for persons age 85 and older. (CABG = coronary artery bypass graft; PCI = percutaneous coronary intervention; p < 0.01.)

Fig 4

Unadjusted 3-year composite outcomes (not mutually exclusive) for patients age 85 and older. (CABG = coronary artery bypass graft; PCI = percutaneous coronary intervention; p < 0.01 for all groups.)