Clinical Efficacy of Different Treatments for Octogenarians with CAD

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Clinical Efficacy of Different Treatments and Their Impacts on the Quality of Life of Octogenarians with Coronary Artery Disease

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality among octogenarians (individuals aged ≥80 years), a rapidly growing demographic in aging societies such as China. Despite the high prevalence of CAD in this age group, octogenarians are often underrepresented in clinical trials, leading to uncertainty regarding optimal management strategies. This study evaluated the clinical efficacy and quality-of-life outcomes associated with three treatment modalities—percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and medical therapy—in 519 octogenarians with CAD.

Introduction

CAD is a major contributor to mortality and healthcare burden in older adults. Octogenarians with CAD often present with complex pathologies, including extensive coronary calcification, multi-vessel disease, and comorbidities such as diabetes and heart failure. While PCI and CABG are established revascularization strategies, their application in octogenarians is limited due to perceived risks and limited evidence. Medical therapy, though commonly used, may not sufficiently address severe ischemia. This study aimed to compare mortality rates, re-hospitalization, bleeding events, and quality-of-life outcomes across treatment groups to guide clinical decision-making.

Methods

Study Population

A retrospective cohort of 519 octogenarians with CAD (mean age: 81.3 years) treated at Beijing Anzhen Hospital from 2010–2016 was analyzed. Patients were stratified into three groups:

  • PCI group (n=292): Underwent stent implantation or angioplasty via transradial/transfemoral approaches.
  • CABG group (n=110): Received on-pump/off-pump bypass surgery.
  • Medical therapy group (n=117): Treated with aspirin, statins, and anti-anginal medications.

Inclusion criteria: Age ≥80 years, ≥50% stenosis in at least one major coronary artery. Exclusion criteria: Prior CABG, malignancies, severe infections, or contraindications to antiplatelet therapy.

Data Collection

Baseline characteristics, angiographic findings, and outcomes were recorded. Follow-up (median: 25 months; range: 17–55.5 months) tracked all-cause death, cardiovascular death, re-hospitalization, bleeding events, and quality of life using the Seattle Angina Questionnaire (SAQ). The SAQ evaluated five domains: physical limitation (PL), angina stability (AS), angina frequency (AF), treatment satisfaction (TS), and disease perception (DP).

Results

Baseline Characteristics

Groups were comparable in age, sex, BMI, and comorbidities (hypertension, diabetes). However, the CABG group had higher rates of three-vessel disease (80.9% vs. 38.4% PCI, 41% medical) and left main (LM) involvement (28.2% vs. 10.3% PCI, 11.1% medical) (P<0.001). PCI patients more frequently presented with acute myocardial infarction (STEMI/NSTEMI: 27.1% vs. 10.9% CABG, 15.4% medical; P<0.001).

Mortality

  • All-cause mortality: Highest in the medical therapy group (28.2% vs. 12.0% PCI, 14.6% CABG; P<0.001).
  • Cardiovascular mortality: Similarly elevated with medical therapy (15.4% vs. 3.8% PCI, 6.4% CABG; P<0.001).
  • Adjusted logistic regression confirmed lower cardiovascular death risk with PCI (odds ratio [OR]=0.28; 95% CI: 0.12–0.66) and CABG (OR=0.54; 95% CI: 0.19–1.59) versus medical therapy.

Re-Hospitalization

CABG demonstrated superior outcomes:

  • Re-hospitalization for cardiovascular events (angina, MI, heart failure) was lowest in the CABG group (3.8% vs. 12.8% PCI, 14.9% medical; P=0.018).

Bleeding Events

No significant differences in cerebral hemorrhage, gastrointestinal bleeding, or dermal ecchymosis were observed among groups (P=0.282–0.967).

Quality of Life (SAQ Scores)

  • PCI and CABG groups outperformed medical therapy in PL, AF, TS, and DP domains (P<0.05).
  • Example: Median TS scores were 82.35 (PCI) and 88.24 (CABG) versus 70.59 (medical); DP scores were 66.67 (PCI/CABG) versus 54.17 (medical).
  • No differences in AS scores were noted (P=0.204).

Discussion

This study underscores the superiority of revascularization (PCI/CABG) over medical therapy in octogenarians with CAD. Key findings include:

  1. Mortality Reduction: PCI and CABG were associated with 50–70% lower cardiovascular mortality versus medical therapy. This aligns with prior studies highlighting the benefits of revascularization in high-risk elderly populations.

  2. Complex Lesions and CABG: The CABG cohort had higher rates of three-vessel and LM disease, reflecting guideline recommendations for surgical revascularization in complex anatomy. Despite this complexity, CABG outcomes were comparable to PCI, suggesting its viability in high-risk cases.

  3. Re-Hospitalization: Lower re-hospitalization with CABG may reflect more complete revascularization, reducing residual ischemia.

  4. Safety: Bleeding risks were comparable across groups, supporting the safety of dual antiplatelet therapy post-revascularization in octogenarians.

  5. Quality of Life: Improved SAQ scores with PCI/CABG highlight the functional benefits of revascularization, which alleviates symptoms and enhances daily living.

Clinical Implications

  1. Revascularization Feasibility: PCI and CABG are safe and effective in octogenarians, even with complex disease.
  2. Individualized Treatment: CABG should be considered for multi-vessel/LM disease, while PCI is suitable for acute coronary syndromes.
  3. Guideline Updates: Current guidelines may undervalue revascularization in the elderly; this study supports broader application.

Limitations

  1. Retrospective Design: Potential selection bias and unmeasured confounders.
  2. Follow-Up Loss: 18.1% lost to follow-up, though rates were balanced across groups.
  3. Medication Data: Limited details on adjunct therapies (e.g., beta-blockers, ACE inhibitors).

Conclusion

In octogenarians with CAD, PCI and CABG significantly reduce mortality and improve quality of life compared to medical therapy. These findings advocate for a paradigm shift toward more aggressive revascularization in this high-risk population, tailored to anatomical complexity and clinical presentation.

doi.org/10.1097/CM9.0000000000000504

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