Observational data have demonstrated that patients presenting with acute coronary syndromes (ACS) and multivessel coronary artery disease (MV-CAD) experience improved 1-year outcomes including lower rates of death, rehospitalization, and repeat ACS when treated with coronary artery bypass graft (CABG) compared with percutaneous coronary intervention (PCI) and medical management (MM). However, limited data exists that studies these practices in adults over the age of 75. This retrospective, multi-centered, observational study from 2018 to 2022 from a healthcare center in Texas compared outcomes among patients with ACS and MV-CAD, stratified by revascularization strategy and age group (<75 vs ≥75 years). The primary endpoint was 1 year mortality, and secondary endpoints include readmission or myocardial infarction (MI) within 1 year, index length of stay, and repeat revascularization within 30 days and 1 year. Cox proportional hazards modeling was used to evaluate the effect of age on mortality outcomes. A total of 2161 patients met inclusion criteria ( n = 1559 CABG, n = 295 PCI, and n = 307 MM). There were 1547 patients under the age of 75 (median age 63.82, IQR = 57.24, 69.44) and 614 over the age of 75 (median age 80.43, IQR = 77.62-84.58). Patients who underwent CABG had significantly reduced mortality compared with PCI or MM (RR = 0.324, CI 0.172 to 0.612, p <0.0001). In conclusion, CABG was associated with improved and comparable outcomes in patients with ACS and MV-CAD both under and over 75 years of age compared with PCI and MM.
Older adults, particularly those aged 75 years and above, represent a rapidly growing population with a high prevalence of multivessel coronary artery disease (MV-CAD) and are increasingly presenting with acute coronary syndromes (ACS). Despite this, current evident guiding optimal revascularization strategies in older adults remains largely derived from meta-analyses and retrospective studies rather than prospective randomized trials. Concerns regarding frailty, procedural risk, and futility have historically led to underrepresentation of elderly patients in randomized trials. According to the 2020 U.S. Census, the population aged 75 to 84 increased by more than 25% from 2010 to 2020 and now exceeds 16 million individuals. Age has been described as the strongest nonmodifiable risk factor for CAD which contributes to vascular and physiologic changes that exacerbate the underlying pathophysiology of CAD. As this population continues to expand, understanding the comparative effectiveness of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and medical management (MM) in those over 75 years is increasingly important. Prior observational studies, including our own, have shown CABG to be associated with improved outcomes compared with PCI or MM in patients with ACS and MV-CAD. However, few data directly compare treatment strategies across age strata. This study therefore aimed to evaluate outcomes with CABG, PCI, and MM in patients with ACS and MV-CAD, stratified by age (<75 vs ≥75 years).
Methods
This was a retrospective, multicentered, observational study, funded by The Baylor Scott & White Health Research Foundation Cardiovascular Research Review Committee, that compares data from patients who underwent revascularization (either CABG or PCI) and those who underwent medical management alone. From 2018 to 2022, the outcomes of patients with ACS and MV-CAD were assessed. Data was collected from patients who presented with ACS and who underwent cardiac catheterization showing at least one coronary artery with a at least 70% occlusion or who were physiologically shown to have ischemia. The details of this study have been previously described. Through electronic record health data extraction, demographics and baseline clinical characteristics were collected and the patients were stratified into CABG, PCI, or MM cohorts respectively based on an intention to treat analysis. Baseline demographics including age, sex, race, height, weight, BMI, and smoking status were recorded. Significant comorbid conditions in the population over the age of 75 include congestive heart failure (CHF), cardiovascular disease (CVD), dementia, chronic kidney disease (CKD), and atrial fibrillation (A-fib).
The primary endpoint analyzed was all cause mortality at 1 year after index ACS event. Secondary endpoints include readmission, MI within 1 year, index length of stay, and repeat revascularization within thirty days and within 1 year. Sample characteristics are reported using descriptive statistics. Frequencies and percentages are used to describe categorical variables. Means and standard deviations (or medians and ranges where appropriate) are used to describe continuous variables. Chi-square tests (or Fisher’s exact tests when small cell counts are present) are used to assess associations between age groups and categorical variables. Two sample t-tests (or Wilcoxon rank-sum tests when data are skewed) are used to test for differences in continuous variables between age groups. Cox proportional hazards models are used for time to event outcomes. Generalized linear mixed models are used to assess relationships with length of stay. Statistical significance is determined by p <0.05. SAS 9.4 was used to perform all statistical analyses.
Results
We identified 2161 unique patients with similar baseline demographics listed in Table 1 who met the inclusion criteria for this study. There were 1559 CABG patients, 295 PCI patients, and 307 MM patients. There were 1547 enrolled patients under the age of 75 (median age of 63.82 [IQR 57.24-69.44]) and 614 over the age of 75 (median age 80.43 [IQR 77.62-84.58]). Table 2 details comorbidities of the cohort.
Table 1
Demographics and clinical characteristics of the patients at time of index acute coronary syndrome event broken down in the entire cohort and those less than 75 years of age as well as those 75 years of age and older
| N = 2161 | Age <75 | Age ≥75 | |||||||
|---|---|---|---|---|---|---|---|---|---|
| N = 1547 |
PCI
N = 1100 |
CABG
N = 241 |
Medically Managed
N = 206 |
N = 614 |
PCI
N = 459 |
CABG
N = 54 |
Medically Managed
N = 101 |
||
| Age | |||||||||
| Median (IQR) | 68.31 (60.13-76.21) | 63.82 (57.24-69.44) | 63.66 (57.08-69.19) | 64.54 (58.62-69.58) | 64.67 (57.45-70.02) | 80.43 (77.62-84.58) | 80.98 (77.83-84.81) | 78.11 (76.6-80.45) | 80.09 (77.35-85.23) |
| Sex | |||||||||
| Female | 641 (29.66%) | 421 (27.21%) | 301 (27.36%) | 66 (27.39%) | 54 (26.21%) | 220 (35.83%) | 181 (39.43%) | 13 (24.07%) | 26 (25.74%) |
| Male | 1520 (70.34%) | 1126 (72.79%) | 799 (72.64%) | 175 (72.61%) | 152 (73.79%) | 394 (64.17%) | 278 (60.57%) | 41 (75.93%) | 75 (74.26%) |
| Race | |||||||||
| White or Caucasian | 1763 (81.58%) | 1236 (79.9%) | 872 (79.27%) | 192 (79.67%) | 172 (83.50%) | 527 (85.83%) | 387 (84.31%) | 49 (90.74%) | 91 (90.1%) |
| Black or African American | 209 (9.67%) | 161 (10.41%) | 119 (10.82%) | 20 (8.30%) | 22 (10.68%) | 48 (7.82%) | 41 (8.93%) | 1 (1.85%) | 6 (5.94%) |
| Other | 189 (8.75%) | 150 (9.70%) | 109 (9.90%) | 29 (12.03%) | 12 (5.83%) | 39 (6.35%) | 31 (6.75%) | 4 (7.41%) | 4 (3.96%) |
| Height (in) | |||||||||
| Median (IQR) | 68 (65-70.98) | 68 (65-71) | 68 (65-71) | 67.99 (65-71) | 68 (65.35-71) | 67.01 (63.5-70) | 67 (63-70) | 68 (66-72) | 68 (64-70) |
| Weight (lbs) | |||||||||
| Median (IQR) | 187 (161-217.81) | 192.79 (167.31-224.63) | 192.69 (166.88-225) | 192 (170-221) | 195 (167-223.13) | 175 (149.25-200) | 173 (147.94-196.1) | 181.19 (160.25-200.19) | 180.75 (150-209.13) |
| BMI | |||||||||
| Median (IQR) | 28.6 (25.4-32.7) | 29.4 (26.1-33.5) | 29.5 (26.1-33.7) | 29.5 (26.1-33.1) | 28.8 (25.5-33.3) | 27.1 (24-30.4) | 26.9 (24.1-30.3) | 27.6 (24.1-30.8) | 27.6 (23.7-31.1) |
| Smoking status | |||||||||
| Missing | 468 (21.66%) | 310 (20.04%) | 235 (21.36%) | 34 (14.11%) | 41 (19.9%) | 158 (25.73%) | 127 (27.67%) | 4 (7.41%) | 27 (26.73%) |
| Current | 307 (14.21%) | 279 (18.03%) | 204 (18.55%) | 46 (19.09%) | 29 (14.08%) | 28 (4.56%) | 20 (4.36%) | 5 (9.26%) | 3 (2.97%) |
| Former | 525 (24.29%) | 339 (21.91%) | 233 (21.18%) | 55 (22.82%) | 51 (24.76%) | 186 (30.29%) | 127 (27.67%) | 21 (38.89%) | 38 (37.62%) |
| Non | 861 (39.84%) | 619 (40.01%) | 428 (38.91%) | 106 (43.98%) | 85 (41.26%) | 242 (39.41%) | 185 (40.31%) | 24 (44.44%) | 33 (32.67%) |
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