The Fate of Coronary Artery Bypass Grafting in the Elderly: Treat and Forget - European Medical Journal

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The Fate of Coronary Artery Bypass Grafting in the Elderly: Treat and Forget

1 Mins
Cardiology
Authors:
Elisa Gastino,1 Matteo Scarpanti,1 Nicolò Vitale,1 Stefano Rosato,2 Giovanni Baglio,3 Alessandro Parolari,1 *Fabio Barili,4,5,6 Paola D’Errigo2
  • 1. University Unit of Cardiac Surgery, IRCCS Policlinico S. Donato, Università Degli Studi Di Milano, Italy
  • 2. National Centre for Global Health, Italian Health Institute, Rome, Italy
  • 3. Agenzia Regionale per i Servizi Sanitari Regionali, Rome, Italy
  • 4. IRCCS Ospedale Galeazzi - Sant’Ambrogio, Milan, Italy
  • 5. Department of Biomedical and Clinical Sciences, Università Degli Studi Di Milano, Italy
  • 6. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
*Correspondence to [email protected]
Disclosure:

Barili has received consulting fees from Abbott. The authors declare no conflicts of interest.

Citation:
EMJ Cardiol. ;12[1]:36-38. https://doi.org/10.33590/emjcardiol/GBEC8594.
Keywords:
Age, coronary artery bypass grafting, myocardial infarction, myocardial revascularisation, octogenarians.

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.

INTRODUCTION

Coronary artery bypass grafting (CABG) is a treatment option offered to a growing population of octogenarians, considering the constant rise in life expectancy.1 The dark side of surgical myocardial revascularisation for octogenarians is the lack of information on follow-up and comparability of mid-term outcomes with younger patients,2 as well as the benefits of tertiary prevention (mid-term management of coronary artery disease after CABG).3 Hence, the purpose of this study is to evaluate the 10-year outcomes of octogenarian patients after isolated CABG included in an Italian nationwide prospective registry.4

METHODS

The PRIORITY project was designed to evaluate the long-term outcomes of two large prospective multicentre cohort studies on isolated CABG.5 Patients younger and older than 80 years were identified. The primary endpoints were all-cause mortality and the overall rate of major adverse cardiac and cerebrovascular events (MACCE) at 10 years. Secondary outcomes included the individual components of MACCE. Baseline differences between the study groups were balanced with propensity score matching and inverse probability of treatment weight (IPTW).6 Time to events was analysed using Cox regression and competing risk analysis.7

RESULTS

The cohort consisted of 10,989 patients who underwent isolated CABG with complete baseline clinical characteristics, operative data, and administrative follow-up. Of the patients, 872 (7.9%). The median follow-up time was 7.9 years. As expected, octogenarians showed poorer 10-year survival (hazard ratio [HR]: 3.09; 95% CI: 2.93–3.25; p<0.001) and MACCE (HR: 2.13; 95% CI: 2.04–2.22; p<0.001). Interestingly, although experiencing a higher cumulative incidence of myocardial infarction (MI) at 10 years (HR: 1.39; 95% CI: 1.29–1.50; p<0.001), octogenarians underwent a reduced incidence of 10-year myocardial revascularisation (HR: 0.53; 95% CI 0.48–0.59; p<0.001), corroborating the hypothesis of undertreatment for the elderly (Figure 1).

Figure 1: Inverse probability of treatment weight cumulative incidence of acute myocardial infarction and repeat revascularisation at 10 years.
HR: hazard ratio.

CONCLUSION

The main finding of this study was the opposite effect of advanced age on acute MI and repeat revascularisation. Indeed, apart from the expected worse survival and MACCE, the higher incidence of acute MI in octogenarians is not concordant with repeat revascularisation, which is significantly more represented in younger patients. It suggests a tendency for conservative approaches by managing the patient’s signs and symptoms with medical therapy alone.8 This result opens a debate on the choice of treating the elderly with CABG without guaranteeing clinical assistance comparable to younger patients.9 Clinicians should make meticulous considerations of the risks and benefits for each treatment option considering the personalised nature of cardiovascular medicine and surgery.

References
Ralapanawa U, Sivakanesan R. Epidemiology and the magnitude of coronary artery disease and acute coronary syndrome: a narrative review. J Epidemiol Glob Health. 2021;(2):169-77. Kirov H et al. Comparing outcomes between coronary artery bypass grafting and percutaneous coronary intervention in octogenarians with left main or multivessel disease. Sci Rep. 2023;13(1):22323. Schwann TA et al. Bilateral internal thoracic artery versus radial artery multi-arterial bypass grafting: a report from the STS database. Eur J Cardiothorac Surg. 2019;56(5):926-34. Barili F et al. Lo studio PRIORITY - predicting long term outcomes after isolated coronary artery bypass surgery. G Ital Cardiol. 2021;22(4):327-31. Seccareccia F et al. The Italian CABG outcome study: short-term outcomes in patients with coronary artery bypass graft surgery. Eur J Cardiothorac Surg. 2006;29(1):56-62. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46(3):399-424. Barili F et al. An original model to predict intensive care unit length-of stay after cardiac surgery in a competing risk framework. Int J Cardiol. 2013;168(1):219-25. Tarakji KG et al. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305(4);381-90. Berezhnoi K et al. Effects of complete revascularization on long-term treatment outcomes in patients with multivessel coronary artery disease over 80 years of age admitted for acute coronary syndrome. Cardiovasc Diagn Ther. 2019;9(4):301-9.

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