Clinical features and outcomes of revascularization in very old patients with left main coronary artery disease

Abstract

Background Coronary artery disease (CAD) is often more extensive in older adults and may involve multivessel and left main coronary artery (LMCA) disease. Elderly patients are commonly excluded from clinical trials, and limited real-world data exist on the management of LMCA disease in the very old. We aimed to investigate clinical features and outcomes of very old patients undergoing revascularization due to LMCA disease. Patients and methods A retrospective single-center analysis of patients at least 80 years (n = 139) who underwent revascularization owing to CAD involving unprotected LMCA stenosis more than 50% was conducted. Subsequent major adverse cardiovascular events (MACE: myocardial infarction, stroke, and all-cause death) and repeat revascularizations were recorded, and their relation to revascularization procedure was studied. Results Percutaneous coronary intervention (PCI) was performed in 74 patients and coronary artery bypass surgery (CABG) in 65. Most patients (80%) had multivessel disease involving at least 2 additional coronary arteries. PCI was associated with older age, higher rates of baseline disability, previous revascularization, reduced ventricular function, significant aortic stenosis, and presentation with acute coronary syndrome, compared with CABG. Cumulative 3-year MACE rates were higher in patients undergoing PCI versus CABG (P = 0.009). After multivariable adjustment, predictors of MACE included presentation with ST-segment elevation myocardial infarction (STEMI) [hazard ratio (HR) = 2.39; 95% confidence interval: 1.24–4.63; P = 0.010], revascularization by PCI compared with CABG [HR = 2.21 (1.18–4.15); P = 0.013], baseline disability [HR = 2.17 (1.20–3.91); P = 0.010], and distal LMCA disease [HR = 1.87 (1.04–3.38); P = 0.038]. The difference in 3-year MACE between PCI and CABG was not observed in a propensity-score analysis of 90 patients matched 1: 1 for baseline disability, STEMI, and aortic stenosis (P = 0.797). Conclusion In very old patients undergoing coronary revascularization owing to LMCA disease, PCI was associated with worse cardiovascular outcomes compared with CABG, influenced by a more severe and comorbid population selected for PCI. Baseline disability, presentation with STEMI, and distal LMCA bifurcation disease were additional independent outcome predictors.

Comparative Clinical Outcomes of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting in Left Main Coronary Artery Disease: Impacts of the SYNTAX score I, II and SYNTAX score II 2020

“…Nevertheless, the PCI group had higher risks for MI and repeat revascularization, aligning with prior research 27,[31][32][33] . Among the eight patients experiencing MI in the PCI group of our study, ve incidents related to target lesion revascularization (TLR).…”

“…Landmark trials like EXCEL and PRECOMBAT showed comparable outcomes between PCI and CABG for patients with low to intermediate anatomical complexity 3,4 . Consequently, guidelines classify PCI as a class I recommendation for LMCAD with a low SS I (0-22), a Class IIA recommendation for LMCAD for an intermediate SS I (23)(24)(25)(26)(27)(28)(29)(30)(31)(32), but a class IIIB recommendation for a high SS I 5,6 . However, high SS I patients with LMCAD, excluded from EXCEL and PRECOMBAT, may still treated by PCI in contemporary real-world practice 7,8 .…”

Percutaneous coronary intervention in patients aged 80 years old and above: a systematic review and meta-analysis

“…Clinicians may need to consider closer follow-up in the longer term. However, it is also important to note that the studies pooled for the 3-year outcomes included papers that compared CABG vs PCI outcomes 40,41 , of which one study had patients with multivessel disease 41 , and one study had patients with left main disease 42 ; hence, the data might have been confounded by the severe underlying disease. However, more studies are required to further explore the implications of these observations and to determine if current clinical practice is sufficient to manage the long-term outcomes of senior patients with ACS undergoing PCI.…”

The Effect of Periprocedural Clinical Factors Related to the Course of STEMI in Men and Women Based on the National Registry of Invasive Cardiology Procedures (ORPKI) between 2014 and 2019

“…In a single-center retrospective study, Sliman et al analyzed 139 patients aged 80 and older who underwent either PCI or CABG. Most patients in the study population had multi-vessel coronary artery disease and critical lesions in the LMCA [ 27 ].…”