Coronary Revascularization in Older Adults After a Myocardial Infarction

Please see the clinical vignette/poll, and poll results/brief discussion. To further expand on this topic, we summarize below a recent observational study of revascularization strategies in older adults after a myocardial infarction (MI) and provide a geriatric cardiology perspective on this topic.

GERIATRIC CARDIOLOGY PERSPECTIVE

  1. The changing United States demographic shift will result in a higher prevalence of older adults with cardiovascular diseases requiring care by the cardiovascular team.
  2. It is imperative that coronary revascularization strategies (medical, percutaneous, or surgical) in older adults presenting with an acute coronary syndrome (ACS) be made based on not only cardiac conditions (cardiac symptoms, ejection fraction, associated atrial fibrillation, associated valvular diseases, coronary anatomy, etc.) but also on geriatric conditions exemplified by the 4Ms (Mind [dementia, mild cognitive function, depression], Mobility [gait speed, presence or absence of frailty], Medications [the role polypharmacy will play in health outcomes]).
  3. The 4th M (What Matters Most) may require a direct question to patients and families: "What is the overarching goal" (for example, a patient may state that his overarching goal would be to go fishing with his children once a week – a very specifically defined overarching goal)?

Background: The optimal coronary revascularization strategy after an MI in older adults with concomitant geriatric conditions is still under debate. Small, randomized studies have suggested benefit while observational studies report mixed data.

Rationale for Study:1 Assess benefit of coronary revascularization after an MI in adults ≥80-years.

Funding: None

Methods:

  • Single-center (Kaiser Permanente, Los Angeles Medical Center) retrospective, observational study.
  • Heart Team (senior cardiothoracic surgeons, general cardiologists, and interventional cardiologists) recommended approach based on coronary anatomy complexity, comorbidities, frailty, dementia, other patient characteristics with patient goals of care and preferences considered.
  • Inclusion criteria: Adults ≥80-years who underwent invasive coronary angiography for acute MI with troponin level greater than 0.04ng/ML.
  • Exclusion criteria: Age <80-years, not a health plan enrollee at time of angiography, concomitant valvular disease (defined as moderate or greater in any valve location), endocarditis, subclavian stenosis. Patients with an absence of ˃50% stenosis in any coronary vessel were excluded from the analysis.
  • Outcomes: All-cause mortality, nonfatal MI, repeat revascularization.

Statistical Analysis:  Propensity score and inverse probability of treatment weighting (IPTW) used to control for known confounders and to attempt to decrease confounding by indication. Cox proportional hazards modeling with hazard ratio (HR).

Results
Overview

  • Total N=1,433; coronary artery bypass grafting (CABG) =176 (12.3 %), percutaneous coronary intervention (PCI) =714 (49.8%), medical therapy= 543 (37.9%).  
  • Median age=83.5 years (interquartile range 81.5-86.2) with majority male (62%).
  • CABG group were slightly younger, more likely to have left main involvement. PCI group less likely to be diabetics, more likely to have had prior PCI. Medical group were more likely to be black, lower left ventricular ejection fraction (LVEF), ≥1 chronic total occlusion, higher comorbidity prevalence and medication burden.
  • Median follow up 2.6 years (IQR 1-4.8 years).

Kaplan-Meier Estimates
All-cause mortality

  • PCI: 319/714 (45%); CABG: 72/176 (41%); medical therapy: 321/543 (59%)
  • Compared with PCI or CABG, medical therapy had the highest incidence of all-cause mortality (p<0.001 between all groups).
  • PCI had the highest incidence of repeat coronary revascularization compared with CABG or medical therapy (P<0.05).

Cox Proportional Hazards Analysis - IPTW Hazard Ratio

  Mortality Nonfatal MI Repeat Revasc
Any Revasc vs. medical therapy 0.66 (0.60-0.73) 0.68 (0.58-0.78) 1.60 (1.15-2.23)
PCI vs. medical therapy 0.70 (0.63-0.78) 0.71 (0.61-0.83) 1.77 (1.26-2.51)
CABG vs. medical therapy 0.58 (0.50-0.67) 0.51 (0.41-0.65) 0.97 (0.55-1.72)
PCI vs. CABG 1.08 (0.94-1.24) 1.61 (1.28-2.03) 2.85 (1.77-4.58)

*Revasc-=revascularization

Subgroup analysis: Revascularization was noted to be better in multiple subgroups except in blacks HR 1.19 (0.87-1.64), and in those with prior CABG HR 0.95 (0.78-1.16).

Conclusions: Investigators concluded that a strategy of coronary revascularization is superior to medical therapy in adults over 80-years after an MI to reduce the incidence of all-cause mortality and nonfatal MI.

Limitations of study:

  • Lack of randomization, despite advanced causal modeling using propensity score and IPTW, limits knowledge of comparative effectiveness between revascularization strategies.
  • Insufficient data regarding geriatric specific conditions such as dementia, physical function, frailty, patient-centered goals of care.
  • It is important to recognize that confounding by indication is best controlled by randomized clinical trials.

References

  1. Phan DQ, Rostomian AH, Schweis F, et al. Revascularization versus medical therapy in patients aged 80 years and older with acute myocardial infarction. J Am Geriatr Soc 2020;68:2525-33.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Nuclear Imaging, Sleep Apnea

Keywords: Geriatrics, Stroke Volume, Percutaneous Coronary Intervention, Coronary Angiography, Coronary Vessels, Cardiovascular Diseases, Propensity Score, Acute Coronary Syndrome, Atrial Fibrillation, Retrospective Studies, Troponin, Constriction, Pathologic, Frail Elderly, African Americans, Polypharmacy, Follow-Up Studies, Kaplan-Meier Estimate, Random Allocation, Ventricular Function, Left, Coronary Artery Bypass, Endocarditis, Comorbidity, Surgeons, Heart Valve Diseases, Patient-Centered Care, Outcome Assessment, Health Care, Patient Care Planning, Dementia


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