Revascularization Versus Medical Therapy in Patients Aged 80 and Older With Stable Ischemic Heart Disease

Derek Q. Phan MD; Ray Zadegan MD; Ming-Sum Lee MD, PhD

Disclosures

J Am Geriatr Soc. 2021;69(12):3457-3467. 

In This Article

Abstract and Introduction

Abstract

Background: Older patients are underrepresented in landmark randomized trials for stable ischemic heart disease (SIHD). Therefore, we sought to evaluate the benefits of revascularization in patients ≥80 years old with SIHD.

Methods: Retrospective study of patients undergoing invasive coronary angiography (ICA) for SIHD between 2009 and 2019. Patients were grouped according to treatment: revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) versus initial medical therapy alone. Inverse probability of treatment weighting (IPTW)-adjusted Cox proportional hazard regression analyses were performed. Outcomes evaluated were all-cause mortality, non-fatal myocardial infarction (MI), and repeat revascularization.

Results: A total of 1015 patients (median age 83.0, interquartile range [IQR] 81.3–85.2 years; 29% female) underwent ICA for SIHD. Of these, 557 (55%) were treated with revascularization and 458 (45%) with initial medical therapy alone. Baseline characteristics were well balanced after IPTW adjustment. At median follow-up of 3.5 years (IQR 1.7–5.9 years), there were no differences in all-cause mortality and non-fatal MI between treatment groups; but there was an increased need for repeat revascularization (IPTW adjusted hazard ratio 2.22, 95% confidence interval 1.53–3.22) with revascularization. Separately comparing PCI or CABG alone versus medical therapy yielded similar results; as well as in subgroup analysis (except for patients ≥90 years old and those without prior CABG).

Conclusion: There were no differences in all-cause mortality and non-fatal MI with invasive revascularization (either PCI or CABG) versus medical therapy alone in patients ≥80 years old with SIHD. Large randomized trials focusing on older patients are warranted to guide clinical practice in this growing population.

Introduction

Coronary artery disease (CAD) is one of the leading causes of death (~360,000 people in 2016) in the United States.[1] The incidence and prevalence of the coronary heart disease significantly increases with age.[2] With a growing older population, data to guide diagnosis and management of CAD in patients ≥80 years of age are ever increasingly important. Unfortunately, there is a paucity of data in older patients given the underrepresentation of this age group in randomized clinical trials.[3,4] Real-world observational studies have provided valuable insights into the effectiveness of treatments in older patients. For example, we and others have shown statins to be beneficial in adults ≥80 years of age for secondary prevention and adults ≥75 years of age for primary prevention.[5,6] We and others have also found benefit with an initial invasive revascularization strategy in adults ≥80 years of age presenting with acute myocardial infarction (MI).[7,8] Despite this, more work is essential to better understand and improve cardiovascular outcomes in this growing but understudied population.

In stable ischemic heart disease (SIHD), invasive revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in addition to guideline-directed medical therapy (GDMT) versus GDMT alone has been studied in clinical trials. Landmark randomized trials, including: COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes), FAME II (Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2), ORBITA (Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty), and ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) compared invasive revascularization versus medical therapy alone—and all had similar findings showing no reduction in mortality with invasive revascularization.[9–13] Unfortunately, older patients were largely underrepresented in these trials, with the average age of patients ranging from 61 to 67 years old; hence, limiting translation of findings to this age group. An exception was the TIME study, but this trial was relatively small in comparison.[14] This trial focused on older patients with SIHD and found no difference in mortality between invasive revascularization versus medical therapy alone, but showed benefit in symptom relief and quality of life.[14,15] To the best of our knowledge, there are no large observational studies dedicated to studying revascularization strategies in older patients with SIHD in the current literature. Given the lack of data in this unique age group, we sought to elucidate the benefits of initial invasive revascularization (with either PCI or CABG) versus medical therapy alone in patients ≥80 years of age with SIHD in a large community-based setting.

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