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Effect of age in the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial
C J Mullany1, M B Mock, M M Brooks
1Mayo Clinic, Rochester, Minnesota, USA.
Insights
Older patients with multivessel coronary disease benefit from either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG), with CABG showing better outcomes in reducing angina and repeat procedures.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- The optimal revascularization strategy for patients with multivessel coronary artery disease, considering age, remains a subject of debate.
- Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) are primary interventions for myocardial revascularization.
Purpose of the Study:
- To evaluate the comparative effectiveness of PTCA versus CABG in different age groups undergoing myocardial revascularization.
- To assess long-term outcomes, including mortality, angina relief, and need for repeat procedures, based on age and treatment allocation.
Main Methods:
- The Bypass Angioplasty Revascularization Investigation (BARI) trial enrolled 1,829 patients with symptomatic multivessel coronary artery disease.
- Patients were randomized to receive either CABG or PTCA.
- Outcomes were analyzed in two age cohorts: younger than 65 years and 65 years or older.
Main Results:
- In-hospital mortality was low for both procedures across age groups, with slightly higher rates for PTCA in older patients (1.7% vs. 1.7% for CABG).
- Older patients experienced more strokes after CABG and more heart failure after PTCA compared to younger patients.
- Coronary artery bypass grafting (CABG) provided superior angina relief and reduced the need for repeat procedures in both age groups.
- Five-year survival rates favored CABG over PTCA, particularly in older patients (85.7% vs. 81.4%).
- Overall cardiac mortality at 5 years was higher in the PTCA group, but this difference diminished when diabetic patients were excluded.
Conclusions:
- Both PTCA and CABG are viable options for older patients with multivessel coronary disease, with older patients experiencing less recurrent angina and fewer repeat procedures, especially with CABG.
- Cardiac mortality was higher in older patients assigned to PTCA, a difference not observed in non-diabetic patients.
- The BARI trial suggests that age is an important factor in considering revascularization strategies, with CABG offering potential advantages in long-term outcomes for older individuals.
Background:
The influence of age on the relative success of either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients requiring myocardial revascularization continues to be controversial.
Methods:
In the Bypass Angioplasty Revascularization Investigation (BARI) trial, 1,829 patients with symptomatic multivessel coronary artery disease requiring revascularization were randomly assigned to undergo either CABG or PTCA.
Results:
Seven hundred nine patients (39%) were 65 to 80 years old at baseline; the other 1,120 were younger than 65 years. The in-hospital 30-day mortality rate for PTCA and CABG in the younger patients was 0.7% and 1.1%, respectively, and that for patients 65 years or older was 1.7% and 1.7%, respectively. In older compared with younger patients, stroke was more common after CABG (1.7% versus 0.2%, p = 0.015) and heart failure or pulmonary edema was more common after PTCA (4.0 versus 1.3%, p = 0.011). In both age groups, CABG resulted in greater relief of angina and fewer repeat procedures. The 5-year survival rate in patients younger than 65 years was 91.5% for CABG and 89.5% for PTCA. In patients 65 years or older, the 5-year survival rate was 85.7% for CABG and 81.4% for PTCA. Cardiac mortality at 5 years was greater in patients assigned to the PTCA group than in those assigned to the CABG group. However, no significant treatment differences were noted in cardiac mortality when only nondiabetic patients were examined.
Conclusions:
Within the context of the Bypass Angioplasty Revascularization Investigation trial, older patients with multivessel coronary disease do well with either PTCA or CABG. Compared with younger patients, older patients had less recurrent angina and were less likely to undergo repeat procedures, particularly among those assigned to undergo CABG. Cardiac mortality was greater in patients 65 years or older assigned to undergo PTCA; however, this difference was not noted when treated diabetic patients were excluded from analysis.