Background
Very elderly patients are under-represented in randomized trials evaluating revascularization for stable ischemic heart disease (SIHD). We sought to evaluate the benefits of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in very elderly diabetics with SIHD.
Methods
Retrospective study of patients aged
>80 years with diabetes and SIHD referred for 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. Cox proportional hazard regression analysis was used to evaluate the primary composite outcome of all-cause mortality, non-fatal myocardial infarction (MI), and repeat revascularization.
Results
A total of 447 patients (average age 83.5±2.8 years, 32% female) were included. Of these, 191 (42.7%) underwent PCI, 55 (12.3%) underwent CABG, and 202 (45.2%) were treated with initial medical therapy. Compared to medical therapy, those revascularized were more likely to have left main disease (22% vs 15, p=0.042), higher ejection fraction (56.7±12.7 vs 53.7±13.7% , p=0.02), and be taking a P2Y12 inhibitor (28% vs 18%, p=0.01); and less likely to have
>1 chronic total occlusion (CTO) (34% vs 62%, p<0.001), prior CABG (27% vs 42%, p<0.001), myocardial infarction (22% vs 31%, p=0.029), COPD (19% vs 27%, p=0.045), PVD (67% vs 80%, p=0.003), and atrial fibrillation (21% vs 32%, p=0.012). Median follow-up was 34.4 months (interquartile range 14.5-61.7months). On multivariate analysis there were no significant differences between groups with respect to the primary composite outcome (Hazard ratio [HR] 1.11, 95% Confidence Interval [CI] 0.83-1.50, p=0.48). Evaluating all outcomes individually, revascularization was associated with a need for repeat-revascularization (HR 3.1, 95% CI 1.21-7.91), p=0.018), but no difference in mortality (HR 0.91, 95% CI 0.65-1.29, p=0.61) and non-fatal MI (HR 1.08, 95% CI 0.64-1.83, p=0.78).
Conclusions
In diabetics
> 80 years of age, there were no difference in outcomes with revascularization versus medical therapy for stable ischemic heart disease. Further studies are needed in very elderly patients to help improve outcomes.