Effects of Age and Sex on Outcomes After PCI and CABG

Study Questions:

What are the effects of age and sex on clinical outcomes after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG) in a pooled population of the two large-scale all-comer registries?

Methods:

In 25,816 patients enrolled in the multicenter CREDO-Kyoto registry (Cohort-1: n = 9,877, and Cohort-2: n = 15,939), the current study population consisted of 5,651 patients (men: n = 3,998, and women: n = 1,653) with triple-vessel coronary artery disease who were considered to be pertinent in comparing PCI with CABG (PCI: n = 3,165, and CABG: n = 2,486). Patients were divided into three groups according to the tertiles of age: ≤65 years (n = 1,972), 66-73 years (n = 1,820), and ≥74 years (n = 1,859). The primary outcome measure in the current analysis was all-cause death. Other outcome measures included cardiac death, sudden death, noncardiac death, myocardial infarction (MI), stroke, heart failure (HF) hospitalization, and any coronary revascularization. Cumulative incidences were estimated by the Kaplan-Meier method and compared using the log-rank test.

Results:

The excess adjusted mortality risk of PCI relative to CABG was significant in patients ≥74 years of age (hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.10-1.79; p = 0.006), while the risks were neutral in patients ≤65 years of age (HR, 1.05; 95% CI, 0.73-1.53; p = 0.78) and in patients 66-73 years of age (HR, 1.03; 95% CI, 0.78-1.36; p = 0.85) (interaction p = 0.003). The excess mortality risk of PCI relative to CABG was significant in men (HR, 1.24; 95% CI, 1.03-1.50; p = 0.02), and trended to be significant in women (HR, 1.34; 95% CI, 0.98-1.84; p = 0.07), without significant interaction between sex and the mortality risk of PCI relative to CABG (interaction p = 0.40).

Conclusions:

The authors concluded that there was a significant association between age and the mortality risk of PCI relative to CABG, with excess risk in patients ≥74 years of age.

Perspective:

This pooled analysis of two large-scale registries of patients undergoing revascularization reports that CABG as compared with PCI was associated with lower long-term risk for mortality, MI, HF hospitalization, and any coronary revascularization, but with higher risk for stroke. Also, there was a significant association between age and the mortality risk of PCI relative to CABG, with excess risk in patients ≥74 years of age and neutral risk in younger patients. There was, however, no significant sex-related difference in the mortality risk of PCI relative to CABG. It should be noted that CABG could still be a viable option for elderly patients with reasonable operative risk when they have complex anatomy unfavorable for PCI and/or significant risks for future HF such as history of HF and depressed left ventricular function.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease

Keywords: Aged, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Death, Sudden, Geriatrics, Heart Failure, Myocardial Infarction, Myocardial Revascularization, Outcome Assessment (Health Care), Percutaneous Coronary Intervention, Risk, Stroke


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