Impact of revascularization versus medical therapy alone for chronic total occlusion management in older patients

Abstract

Background Chronic total occlusions (CTOs) are present in more than one third of older patients with myocardial ischemia, but controversy remains about the best therapeutic approach. Aims To compare long‐term survival after CTO revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) versus medical treatment (MT) alone in patients aged 75 and older. Methods and results A total of 1,252 consecutive patients with at least one CTO were identified from 2010 to 2014 in our center. Patients were stratified by age (<75 years vs. ≥75 years) in the present analysis. All‐cause and cardiac mortality were assessed at a median follow‐up of 3.5 years. In the older subgroup (26%), patients were more likely to be treated with MT alone (71% vs. 43% of younger patients; p < 0.001). Patients undergoing revascularization were younger and had higher left ventricular ejection fraction (LVEF) and lower age, creatinine, ejection fraction (ACEF) score (age/LVEF +1 if creatinine >2.0 mg/dL), compared to the MT group (p < 0.05). As compared to MT, revascularization predicted lower rates of cardiac mortality and all‐cause mortality in older patients, both in the subgroups treated with CABG (hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.17–0.71; HR 0.39, 95%CI 0.18–0.81) and PCI (HR 0.57, 95%CI 0.33–0.98; HR 0.59, 95%CI 0.28–1.2). No differences in mortality were observed according to type of revascularization procedure. Conclusions Among patients aged at least 75 years with a CTO, revascularization (PCI or CABG) rather than MT alone may portend a better outcome in terms of all‐cause and cardiac mortality.

Survival benefit of revascularization versus optimal medical therapy alone for chronic total occlusion management in patients with diabetes

“…The ACEF score is a simple tool to predict clinical outcomes in patients requiring complex coronary interventions. It has not been used in the setting of diabetes and CTO to date 26,27 ; however, our results show its effectiveness in our cohort of patients with diabetes treated with CTO‐PCI.…”

<p>Percutaneous Coronary Intervention in Elderly Patients with Coronary Chronic Total Occlusions: Current Evidence and Future Perspectives</p>

“…49 In a recent analysis based on 328 patients aged ≥75 years, Flores-Umanzor et al found no significant differences in cardiac death or MI between the PCI and CABG groups. 50 Older patients may be hospitalized longer after CABG. However, physical, psychological and social recovery were similar with those of younger.…”

Clinical Outcomes in Chronic Total Occlusion Revascularization Versus No Chronic Total Occlusion Revascularization: Variability by Target Vessel

“…Although observational studies have shown the benefit of CTO PCI in clinical outcomes compared with medical therapy, no significant difference in 4-year cardiovascular events was found in patients with CTO PCI versus no CTO PCI in the randomized, controlled, DECISION-CTO trial. 1,10 –13 Although this trial was limited by being underpowered for clinical end points and a high crossover rate, the results support an uncertain benefit of CTO revascularization compared with medical therapy or non-CTO treatment. Thus, it has been an alternative strategy to perform non-CTO lesions revascularization while treating the CTO medically in real-world practice.…”