Background
There is limited data on the benefits of revascularization in very elderly patients with left ventricular (LV) dysfunction and stable ischemic heart disease (SIHD). 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 and SIHD.
Methods
Retrospective study of patients
> 80 years old with LV ejection fraction (LVEF)
< 40% and SIHD referred for invasive coronary angiography at Kaiser Permanente Los Angeles Medical Center between April 2009 and February 2019. Patients were grouped by treatment: revascularization (PCI or CABG) versus medical therapy. Cox proportional hazard regression analysis was utilized to evaluate outcomes.
Results
A total of 942 patients (average age 83.6±2.9years, 29% female) were included, of which 143 (15.2%) patients had LVEF
<40%. Amongst patients with LVEF
<40%, those revascularized were less likely to have
>1 CTO (48% vs 68%, p=0.019), and have lower body mass index (BMI) (25.1±3.8 vs 26.9±4.6kg/m2, p=0.013). And amongst patients with LVEF>40%, those revascularized were more likely to have left main disease (20% vs 14%, p=0.02), and less likely to have
>1 CTO (32% vs 59%, p<0.001). Median follow-up was 43.2months (interquartile range 19.9-72.2 months). In patients with LVEF
<40%, revascularization was associated with reduced all-cause mortality (Hazard Ratio [HR] 0.55, 95% Confidence Interval [CI] 0.33-0.92, p=0.022) when adjusting for age, sex, race, diabetes, COPD, PVD, and atrial fibrillation. However, there was no association with mortality in those with normal LVEF (HR 0.98, 95% CI 0.76-1.25, p=0.849) and in the full cohort (HR 0.85, 95% CI 0.69-1.06, p=0.154). There was no association between revascularization and non-fatal MI, regardless of LVEF.
Conclusions
In very elderly patients with LV dysfunction and SIHD, revascularization was associated with improved mortality. No benefit was seen with revascularization in normal LV function, nor with preventing future non-fatal MI events. Further studies in very elderly patients are needed to identify specific groups that may benefit from invasive therapies.