Don’t Rule Out CABG for Elderly Patients With Multiple Comorbidities

Elderly patients with complex geriatric conditions and left main or multivessel coronary artery disease who experience an acute coronary syndrome—particularly NSTEMI or unstable angina—fare significantly better beyond 1 year if they are treated with surgery, according to a new observational study.

Based on the findings, physicians shouldn’t rule out CABG surgery for elderly patients with multiple comorbidities even though it’s the more invasive revascularization strategy, say investigators.

“In clinical practice, the decision is a nuanced one, with the heart team selecting the best revascularization procedure for patients with comorbidities and multivessel CAD,” Ahmed Ijaz Shah, MD (Kaiser Permanente Oakland Medical Center, CA), told TCTMD. “Generally, left main disease [and] multivessel disease, especially in diabetics, are recommended for CABG. Patients with severe kidney disease or very low LV function are considered too high risk for surgery and may be referred for PCI. Clinical frailty, which was not captured by us in our study, is also an important factor, which is seldom objectively checked clinically.”

What shouldn’t be the deciding factor, especially since it is a poor surrogate for frailty, is age. “We contend in this study that age should not be a consideration when deciding between CABG and PCI,” said Shah.

The study was published last week in the Journal of the American Geriatrics Society.

Older Patients, More Ischemic Heart Disease

As the population ages, the incidence of ischemic heart disease is increasing in geriatric individuals, but there are few studies comparing revascularization strategies in elderly adults, particularly in those with age-related comorbidities that can make the revascularization decision somewhat trickier.

To address this question, researchers turned to data from the Kaiser Permanente Northern California health plan database and identified 3,871 patients 65 years and older presenting with ACS between 2010 and 2018 who were subsequently treated with CABG (n = 1,575) or PCI (n = 2,296) for left main or multivessel CAD. After propensity matching, they evaluated the number of days alive out of hospital (DAOH) in 1,087 patients treated with each procedure. Overall, approximately 71% of patients presented with NSTEMI, 22% with unstable angina, and the remainder with STEMI.

At the end of the day it is [patients’] wishes that matter, not an interventional cardiologist’s or surgeon’s ‘need’ to do a procedure, even though it may be technically possible. Ahmed Ijaz Shah

The average age of patients was 73 years and the median Charlson comorbidity index was 3, which reflects a moderate extent of comorbidity. In the matched cohorts, approximately 40% of patients had congestive heart failure, 45% were diagnosed with renal failure, 50% had diabetes mellitus, and 90% had hypertension. Rates of cerebrovascular and peripheral arterial disease also were substantial (approximately 14% and 17%, respectively), while one-third had chronic obstructive pulmonary disease.       

In the propensity-matched analysis, there was no significant difference in the mean number of DAOH between the two procedures at 1 year (335.3 with CABG vs 329.6 with PCI; P = 0.124). By 3 years, however, there was a significant advantage with surgery compared with PCI (963.0 vs 906.6 DAOH) and this benefit even more pronounced by 5 years (1,525.4 vs 1,394.5 DAOH; P < 0.001 for both).

One of the study’s strengths is the selection of DAOH as the primary endpoint, say researchers. DAOH is a patient-centered outcome that captures any reason that leads to an admission for acute care, including for cardiovascular events such as recurrent MI and repeat revascularization, as well noncardiovascular outcomes, such as renal failure or infection.

The researchers say their findings line up with results from the large ASCERT observational study published 10 years ago. In that study of nearly 200,000 adults 65 years and older with multivessel CAD not requiring emergency treatment, CABG surgery was associated with a survival advantage compared with PCI.

Overcoming Fear

To TCTMD, Shah said there can be a fear of CABG surgery for some patients, although some also have concerns about PCI, albeit to a lesser degree.

“I usually tell patients in whom I feel CABG is recommended, [such as] left main, multivessel disease, etc, that based on their angiogram and clinical condition, the best option for revascularization is bypass surgery,” said Shah. “It gives the best long-term benefit with a reduced need for repeat procedures. I tell them that the initial recovery in the first few months is difficult, but if they can tolerate it, then the long-term outlook is far superior compared to stenting. I further tell them that stenting, if anatomically feasible, is the second-best option for revascularization. Given the superiority of surgery, I offer them the ‘best option’ to consider first.”

The newest iteration of the US revascularization guidelines were released in 2021 and state that the revascularization strategy in “older” patients, just as it is in those who are younger, should be based on an individual’s preferences, cognitive function, and life expectancy. In stable patients with left main disease, which differs from the ACS population studied in the Kaiser Permanente database, surgery is preferred (class I, level of evidence B) over PCI (class 2a in patients with low-to-intermediate anatomical complexity). As reported by TCTMD, CABG was recently downgraded from a class 1 to a class 2b recommendation in stable patients with multivessel disease, a decision different surgical groups didn’t agree with. In ACS patients, there are different recommendations for PCI and CABG surgery depending on clinical scenarios, but revascularization is recommended.  

Shah noted that physicians can influence a patient’s decision in how they present evidence, but the responsibility should be to give as much information as possible in a straightforward way so they can make an informed decision. “At the end of the day it is their wishes that matter, not an interventional cardiologist’s or surgeon’s ‘need’ to do a procedure, even though it may be technically possible,” he said.