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In the very elderly—those aged 80 or older—outcomes are similar for percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery out to 5 years after adjusting for key baseline clinical differences, according to findings published online July 4, 2012, ahead of print in the American Journal of Cardiology.

For the observational study, Jarmo Gunn, MD, of Turku University Hospital (Turku, Finland), and colleagues compared outcomes of octogenarians who received PCI (n = 393) or isolated CABG (n = 274) in 2 Finnish centers between 2001 and 2011.

The cohorts differed in important respects: PCI patients were older and more likely to have a history of cardiac surgery, emergency revascularization, or recent MI than CABG patients. On the other hand, CABG patients had a greater prevalence of 3-vessel disease.

No Long-term Disadvantage to PCI

At 30 days, mortality rates were similar for PCI and CABG (7.4% and 8.8%; P = 0.514), although after multivariable adjustment, CABG was associated with higher short-term risk (OR 2.246; 95% CI 1.141-4.422; P = 0.019).

Unadjusted Kaplan-Meier estimates of 5-year survival favored CABG over PCI (72.2% vs. 59.5%; P = 0.004), while freedom from fatal cardiac events was similar for the 2 strategies (P = 0.187). However, the mortality difference disappeared after adjustment for propensity score (P = 0.698).

A separate analysis of 130 pairs of patients propensity matched for baseline characteristics confirmed the equivalence of 5-year survival rates between CABG and PCI (66.4% and 58.9%; P = 0.730).

Logistic regression analysis showed that age, previous cardiac surgery, number of diseased vessels, recent MI, and emergent procedure were all independent predictors of being assigned to PCI or CABG.

A ‘Real World’ Test

“These are actual real-world outcomes from our hospitals,” Dr. Gunn wrote in an e-mail correspondence with TCTMD. “What makes them particularly representative is that these hospitals treat all patients in need of revascularization in their respective catchment areas. Hence, there is no recruitment bias, and all invasively treated octogenarians within the study period are included. It is naturally important to remember that this study does not include patients who were deemed unfit for invasive treatment.”

“Octogenarians have an excellent survival after revascularization,” Dr. Gunn observed. He added that a heart team is needed to select the best treatment for each patient: PCI, CABG, or conservative treatment. “This entails a thorough assessment not only of apparent comorbidities like diabetes and pulmonary disease but also of frailty, dementia, and other less ‘traditional’ risk factors that an experienced interventionalist can readily spot on presentation,” he said.

In a telephone interview with TCTMD, Jeffrey W. Moses, MD, of Columbia University Medical Center/Weill Cornell Medical Center (New York, NY), said the findings show that “PCI isn’t much of a disadvantage and may be in some ways advantageous in the elderly. There is obviously a strong tendency to recommend a less invasive strategy in this age group, and this reinforces that. You’re certainly not doing them a disservice by going along with your instincts.”

Apples to Oranges

But Dr. Moses also emphasized the limitations of the study. “The profound issue with all these types of analyses is there are so many confounders, especially in the elderly,” he said. “With the propensity matching, they don’t include eligibility for surgery or how frail they were. Obviously, the frailest patients get shunted into the PCI group. Even with the matching, you don’t know if you’re comparing apples to apples. How many of these [PCI] patients were deemed inoperable? You see hints of it because PCI patients are sicker and have more comorbidities, but it really needs to be nailed down because at the end of the day, surgical patients need to be compared to patients who are surgically eligible. Otherwise the comparisons are really irrelevant.”

Noting similar concerns, Harlan M. Krumholz, MD, SM, of the Yale School of Medicine (New Haven, CT), said in an e-mail communication with TCTMD that the current study “cannot be considered a well-designed comparative effectiveness study.” However, he added, “it does give us an indication of the long-term outcomes of very old patients undergoing these respective procedures.”

Source:

Gunn J, Kuttila K, Vasques F, et al. Comparison of results of coronary artery bypass grafting versus percutaneous coronary intervention in octogenarians. Am J Cardiol. 2012;Epub ahead of print.

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