Revascularization Versus Medical Therapy in Very Elderly Patients with Baseline Renal Dysfunction for Stable Ischemic Heart Disease
Presenter
Derek Q. Phan, M.D., Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
Derek Q. Phan, M.D.1, Jesse Goitia, M.D.1, Ming-Sum Lee, M.D., PhD1, Brendan Kim, M.D.1, Naing A. Moore, M.D.2, Prakash W. Mansukhani, M.D.3, Vicken J. Aharonian, M.D., FSCAI3, Somjot S. Brar, M.D., FSCAI1 and Ray Zadegan, M.D.1, (1)Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, (2)-, South Pasadena, CA, (3)Kaiser Permanente, Los Angeles, CA
Keywords: Coronary and Stable Ischemic Heart Disease (SIHD)
Background
There is a paucity of data on coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) in very elderly patients with renal dysfunction. Therefore, we sought to evaluate the benefits of revascularization in this unique under-studied population.
Methods
Retrospective study of patients aged
> 80 years with glomerular filtration rate (GFR) < 60 ml/min and SIHD who underwent invasive coronary angiography (ICA) at Kaiser Permanente Los Angeles Medical Center between April 2009 and February 2019. Patients were grouped by treatment: PCI, CABG, or medical therapy alone. Inverse Probability Treatment of Weighting (IPTW) was utilized. All-cause mortality and non-fatal myocardial infarction (MI) were evaluated
Results
A total of 476 patients (average age 83.6±3.0 years, 32% female) were included. Of these, 196 (41%) and 54 (11%) underwent PCI and CABG, respectively. Compared to medical therapy, those revascularized had higher a higher left ventricular ejection fraction (57.6±12.4 vs 54.7±13.8, p=0.019), more likely to be Asian (13.2% vs 7.5%, p=0.044), and to be taking a P2Y12 inhibitor (24% vs 17%, p=0.042); and less likely to have
>1 chronic total occlusion (37% vs 61%, p<0.001), prior myocardial infarction (14% vs 23%, p=0.011), CABG (22% vs 37, p<0.001), and atrial fibrillation (20% vs 29%, p =0.015). Median follow-up was 40.4 months (interquartile range 17.1-67.2 months). After IPTW adjustment (all baseline characteristics well balanced with p>0.05), revascularization was not associated with increased all-cause mortality (IPTW Hazard Ratio [HR] 0.91, 95% Confidence Interval [CI] 0.74-1.12, p=0.4) nor non-fatal MI (IPTW HR 0.77, 95% CI 0.54-1.10, p=0.2).
Conclusions
Revascularization (either PCI or CABG) is not associated with increased mortality or non-fatal MI at long-term follow-up compared to medical therapy in very elderly patients with renal dysfunction and stable ischemic heart disease. Either strategy may be appropriate in this high-risk population. Further studies are needed in very elderly patients to improve outcomes.