Revascularization Versus Medical Therapy in Patients Aged 80 Years and Older With Acute Myocardial Infarction

Derek Q. Phan, MD; Ara H. Rostomian, MD, MBA, MPH; Franz Schweis, MD; Joanie Chung, MPH; Bryan Lin, MS; Ray Zadegan, MD; Ming-Sum Lee, MD, PhD

Disclosures

J Am Geriatr Soc. 2020;68(11):2525-2533. 

In This Article

Abstract and Introduction

Abstract

Background/Objectives: Older patients are underrepresented in acute coronary syndrome clinical trials. We sought to evaluate the benefits of revascularization in patients aged 80 years and older presenting with acute myocardial infarction (AMI).

Design: Retrospective study utilizing inverse probability of treatment weighting (IPTW).

Setting: Single tertiary referral center for an integrated healthcare system in southern California.

Participants: Patients undergoing invasive coronary angiography for AMI between 2009 and 2019, and subsequently treated with percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or medical therapy alone.

Measurements: All-cause mortality, nonfatal myocardial infarction (MI), and repeated revascularization.

Results: A total of 1,433 patients aged 80 years or older (median age = 83.5 years; 66% male) presenting with AMI who underwent treatment with PCI (50%), CABG (12%), or medical therapy alone (38%) were included. Those treated with medical therapy were more likely to be Black, had one or more chronic total occlusions in any vessel, had more comorbidities, and had lower left ventricular ejection fraction. Baseline characteristics were well balanced after IPTW adjustment. Median follow-up was 2.6 years. Revascularization (PCI or CABG) was associated with reduced mortality (hazard ratio (HR) = 0.66; 95% confidence interval (CI) = 0.60–0.73) and nonfatal MI (HR = 0.68; 95% CI = 0.58–0.78), but an increased need for repeated revascularization (HR = 1.60; 95% CI = 1.15–2.23). Separately comparing PCI or CABG alone versus medical therapy yielded similar results. Revascularization was associated with lower mortality in all subgroups, except in Black patients and those with prior CABG.

Conclusion: Revascularization is superior to medical therapy in reducing all-cause mortality and nonfatal MI in patients aged 80 years and older with AMI. Age alone should not preclude patients from potentially beneficial invasive therapies.

Introduction

The annual incidence of acute myocardial infarction (AMI) in the United States is 605,000.[1] Several clinical trials and large observational studies have demonstrated the benefits of coronary revascularization for acute coronary syndrome (ACS).[2–7] As such, guidelines by both the American College of Cardiology (ACC)/American Heart Association (AHA) and European Society of Cardiology recommend an early invasive strategy for the management of non–ST-segment–elevation myocardial infarction (NSTEMI), especially in high-risk groups.[8,9] However, older patients are underrepresented in clinical trials, with the average age of enrolled patients being younger than 65 years, thus limiting the generalizability and translation of clinical trial results to older patients (aged ≥80 years). Additional studies that specifically address the risks and benefits of an invasive strategy in this population are needed.[10–12]

Older patients are at high risk for mortality and adverse events after AMI.[1,13] Due to frailty, multiple comorbidities, and risk for complications, clinicians need to carefully weigh the risks and benefits of invasive therapies. Real-world data show older patients with multiple comorbidities are less likely to receive invasive revascularization for ACS, possibly due to a perceived unfavorable risk-benefit ratio.[6,14,15] Contrary to this belief, subgroup analyses from randomized trials showed older patients to have greater absolute benefit from invasive therapy compared with their younger counterparts.[2,4,5,16]

Few small randomized trials with a focus on old patients with ACS suggest there may be a benefit with revascularization, or at least no detrimental effect.[17–21] However, data from observational studies are mixed.[6,22] Older patients comprise a unique population who may derive tremendous benefit from invasive revascularization but may also experience significant harm. Additional data are needed to further guide the optimal management strategy in this group of patients. The goal of this study is to evaluate the benefits of revascularization, both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), in patients aged 80 years or older presenting with AMI in a large community setting.

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