Introduction:
There is limited data on the benefits of revascularization in very elderly patients with left ventricular (LV) dysfunction and coronary artery disease (CAD). Hence, we sought to evaluate the role of coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in very elderly patients with LV dysfunction who present with acute myocardial infarction (AMI).
Methods:
Retrospective study of patients ≥ 80 years old with LV ejection fraction (LVEF) ≤ 40% referred for invasive coronary angiography for AMI at Kaiser Permanente Los Angeles Medical Center between June 2009 and February 2019. Patients were grouped by treatment: PCI, CABG, or medical therapy. Inverse Probability Treatment of Weighting (IPTW) was utilized.
Results:
A total of 480 patients (average age 84.1±3.3years, 30% female) were analyzed. Of these, 206 (42.9%) underwent PCI and 46 (9.6%) underwent CABG. Compared to medical therapy, those revascularized were less likely to have any chronic total occlusion, prior strokes, diabetes, CAD, peripheral vascular disease, atrial fibrillation, and prior CABG; and more likely to have had prior PCI and higher LVEF. Median follow-up was 24.9 months (interquartile range 7.7-48.7months), After IPTW adjustment, revascularization was associated with a reduction in mortality (Hazard Ratio [HR] 0.72, 95% Confidence Interval [CI] 0.61-0.85) and non-fatal MI (HR 0.58, 95% CI 0.44-0.76). Both PCI and CABG were associated with reduced mortality (PCI: HR 0.75, 95% CI 0.63-0.90; CABG: HR 0.51, 95% CI 0.40-0.66) and non-fatal MI (PCI: HR 0.65, 95% CI 0.49-0.85; CABG: HR 0.28, 95% CI 0.16-0.48). Compared to CABG, there were no differences in mortality (HR 1.27, 95% CI 0.96-1.67), but increased non-fatal MI events (HR 3.81, 95% CI 1.82-8.0) with PCI.
Conclusion:
In very elderly patients with LV dysfunction, revascularization is superior to medical therapy. There were no differences in mortality between PCI and CABG, but PCI was associated with increased non-fatal MI events.
Physiology-guided revascularization versus optimal medical therapy of nonculprit lesions in elderly patients with myocardial infarction: Rationale and design of the FIRE trial