Use of less-invasive percutaneous coronary intervention (PCI) procedures may be preferable over coronary artery bypass graft (CABG) in elderly patients with complex coronary artery disease (CAD), according to new data showing equivalent outcomes.
The findings, published online Monday and in the June 8 issue of the Journal of the American College of Cardiology, report that because no significant difference in 10-year life expectancy or 5-year quality of life (QOL) was seen in the follow-up data, the less-invasive strategy of using PCI rather than CABG may be favored for elderly patients.
However, the team, led by first author Masafumi Ono at the University of Amsterdam and the National University of Ireland, noted that the final treatment decision should be made on an individual basis, integrating the difference of any clinical risks and life expectancy in the context of QOL.
Ono and colleagues noted that CAD is the leading cause of death among elderly patients, who tend to have more complex and severe CAD compared with younger patients.
“In the era of a global aging, discussions on the optimal treatment strategy for elderly patients with complex CAD, taking into account long-term outcomes, are essential and inevitable,” they said, warning that such debates have been hampered by the fact that the majority of trials exclude elderly patients either due to age itself or comorbidities.
“Older patients are frequently more frail than younger patients, and consequently practitioners may be reluctant to recommend an invasive surgical strategy to treat their complex CAD,” said Ono et al., adding that current guidelines do not provide sufficient evidence-based recommendations for the management of elderly patients with complex CAD such as three-vessel disease (3VD) or left main coronary artery disease (LMCAD).
“Our results may facilitate the patient’s understanding and be useful for both the patient and the Heart Team during the decision-making process,” they wrote.
The study was a pre-specified analysis of the SYNTAX Extended Survival study, which looked at 10-year all-cause mortality, life expectancy, 5-year major adverse cardiac or cerebrovascular events (MACCE), and 5-year QOL after PCI or CABG in patients over 70 years old with 3VD or LMCAD, or both.
Of the 1,800 randomized patients enrolled in the SYNTAX trial, 575 (31.9%) were over age 70 and were included in the current analysis, noted the authors.
Within this group, there was no significant difference in 10-year mortality between PCI and CABG (44.0% vs. 41.5%; hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 0.84 to 1.40; p = 0.530), while 5-year MACCE was also comparable between PCI and CABG (39.4% vs. 35.1%; HR: 1.18; 95% CI: 0.90 to 1.56) – a measure that is significantly higher in PCI over CABG among non-elderly patients.
Furthermore, there was no significant difference in life expectancy, with a mean difference of 0.2 years (95% CI: -0.4 to 0.7 years; p = 0.524) and 5-year QOL status between PCI and CABG, said the team.
Given the equivalent long-term survival risk and QOL status between PCI and CABG from the study, Ono and colleagues concluded that the less-invasive strategy of using PCI instead of CABG may be favored for elderly patients and preferred by patients themselves.
Call for Immediate Change
An accompanying editorial penned by Ravi S. Hira, MD, of the Pulse Heart Institute, Tacoma, Washington, warns that with rapid aging of the baby-boom generation, there has been a sharp increase in elderly patients with multivessel disease requiring revascularization.
Hira states that data from the current study show that “old school” PCI is a reasonable alternative to CABG “and should lead to an immediate change in practice.”
However, he noted that the SYNTAX trial was performed with first-generation stents and that since then, second-generation drug-eluting stents that are superior in reducing all-cause mortality, myocardial infarction, stent thrombosis, and major adverse cardiac events have largely replaced the first-generation stents analyzed in the current study.
Hira added that given the improved outcomes seen within the SYNTAX II trial, contemporary PCI may prove to be even better than CABG for elderly patients.
“Moving forward, interventional cardiologists will need to grow their repertoire for contemporary PCI to provide a legitimate alternative to CABG for patients with increasingly complex CAD,” he suggested, noting that with the continued evolution of contemporary PCI, further studies will also need to evaluate whether PCI will prove to be a viable alternative to CABG in younger patients as well.
Ono M, Serruys PW, Hara H, et al. 10-Year Follow-Up After Revascularization in Elderly Patients With Complex Coronary Artery Disease. J Am Coll Cardiol 2021;77:2761-73.
Hira RS. Revascularizing Complex CAD in Elderly Patients: The Coming-of-Age Story of Percutaneous Coronary Intervention. J Am Coll Cardiol 2021;77:2774-6.