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Ono M, Serruys PW, Hara H, et al. 10-Year Follow-Up After Revascularization in Elderly Patients With Complex Coronary Artery Disease. J Am Coll Cardiol. 2021 Jun 8;77(22):2761-2773. doi: 10.1016/j.jacc.2021.04.016. (Original study)

BACKGROUND: The optimal revascularization strategy for the elderly with complex coronary artery disease remains unclear.

OBJECTIVES: The goal of this study was to investigate 10-year all-cause mortality, life expectancy, 5-year major adverse cardiac or cerebrovascular events (MACCE), and 5-year quality of life (QOL) after percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in elderly individuals (>70 years old) with 3-vessel disease (3VD) and/or left main disease (LMD).

METHODS: In the present pre-specified analysis on age of the SYNTAX Extended Survival study, 10-year all-cause death and 5-year MACCE were compared with Kaplan-Meier estimates and Cox proportional hazards models among elderly or nonelderly patients. Life expectancy was estimated by restricted mean survival time within 10 years, and QOL status according to the Seattle Angina Questionnaire up to 5 years was assessed by linear mixed-effects models.

RESULTS: Among 1,800 randomized patients, 575 patients (31.9%) were elderly. Ten-year mortality did not differ significantly between PCI and CABG in elderly (44.1% vs. 41.1%; hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 0.84 to 1.40) and nonelderly patients (21.1% vs. 16.6%; HR: 1.30; 95% CI: 1.00 to 1.69; pinteraction = 0.332). Among elderly patients, 5-year MACCE was comparable between PCI and CABG (39.4% vs. 35.1%; HR: 1.18; 95% CI: 0.90 to 1.56), whereas it was significantly higher in PCI over CABG among nonelderly patients (36.3% vs. 23.0%; HR: 1.69; 95% CI: 1.36 to 2.10; pinteraction = 0.043). There were no significant difference in life expectancy (mean difference: 0.2 years in favor of CABG; 95% CI: -0.4 to 0.7) and 5-year QOL status between PCI and CABG among elderly patients.

CONCLUSIONS: Elderly patients with 3VD and/or LMD had comparable 10-year all-cause death, life expectancy, 5-year MACCE, and 5-year QOL status irrespective of revascularization mode. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050) (SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).

Discipline Area Score
Surgery - Cardiac 6 / 7
Internal Medicine 6 / 7
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Cardiology 6 / 7
Comments from MORE raters

Internal Medicine rater

Tough call. While no significant difference in MACCE, PCI tended higher over 5 years (39.4% vs 35.1%; HR: 1.18; 95% CI: 0.90 to 1.56).

Internal Medicine rater

Definitely useful as we make decisions in our elderly patients.

Surgery - Cardiac rater

CABG has substantial benefits over PCI, but the patient needs to survive long enough to enjoy these benefits. The data show that mortality is a linear function of age, but MACCE is lower in the CABG group until about age 82. At this age, multiple factors influence mortality and the mode of revascularization (PCI or CABG) makes no difference. This does not imply PCI and CABG are similar in the elderly; however, in this group, survival is not solely dependent on myocardial blood flow but on the multiple comorbidities associated with cardiovascular disease.

Surgery - Cardiac rater

Because each patient's care is a test won or lost, focus should be on survival and safety. 10-yr mortality was 44% post-stent vs 41.5 CABG. Applying the data to 10,000 patients (M) as in the WHI study = 350 more CABG patients alive. 5-yr MACE in >70 yr-olds was 39.4% vs 35.1, so 480 more PCI complications/M. And in =70 yr-olds, post-PCI risk was 36.3% vs 23 = 1,330 additional injuries post-PCI (p<0.001). Plus, for all ages, half more frequent post-PCI risks were statistically as well as clinically significant. Thus, the final statement “PCI may represent reasonable alternative to CABG for elderly with complex CAD,” is applicable to selected cases at high risk for surgery. In general, however, patients with PCI have greater complications compared with CABG in 5 of the 6 categories reported. This study can improve safety and reduce costs by informing all concerned that PCI has applications, but late mortality is greater than post-surgery, all complications except stroke are more frequent, and 1-2 drugs that increase bleeding risk are needed for 1 yr.
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