Complete revascularization in elderly patients with multi-vessel disease following acute coronary syndrome: A
António Rocha de Almeida1, Rafael Viana1, Kisa Congo1
1Division of Cardiology of Hospital Espírito Santo de Évora, Unidade Local de Saúde Alentejo Central, Évora, Portugal.
Insights
Complete revascularization (CR) in elderly patients with acute coronary syndromes (ACS) and multivessel disease (MVD) reduced in-hospital deaths and MACE. Long-term outcomes were similar, suggesting individualized treatment strategies are crucial.
Area of Science:
- Cardiology
- Geriatric Medicine
- Interventional Cardiology
Background:
- Acute coronary syndromes (ACS) present unique challenges in the elderly, particularly with multivessel disease (MVD).
- Limited evidence often leads to conservative management in older patients, despite established benefits of complete revascularization (CR) in younger populations.
- Uncertainties remain regarding the optimal revascularization strategy for elderly individuals with ACS and MVD.
Purpose of the Study:
- To compare the effectiveness of complete revascularization (CR) versus culprit-only (CO) revascularization in elderly patients (over 75 years) with ACS and MVD.
- To assess in-hospital and follow-up composite outcomes, including death and major adverse cardiovascular events (MACE).
Main Methods:
- A national multicenter retrospective cohort study involving 629 elderly patients (≥75 years) with ACS and MVD.
- Patients were divided into two groups: complete revascularization (CR) and culprit-only (CO) revascularization.
- In-hospital composite outcomes (death, MACE) and follow-up composite outcomes (death, cardiovascular hospital admission) were analyzed.
Main Results:
- Complete revascularization (CR) was associated with significantly lower in-hospital events, including death and MACE, compared to culprit-only (CO) revascularization.
- In-hospital mortality was lower in the CR group (6% vs. 19%, p < 0.01).
- During follow-up, CR showed non-significant trends towards lower mortality, hospital admissions, and composite outcomes compared to CO.
Conclusions:
- Complete revascularization (CR) in elderly patients with ACS and MVD demonstrated reduced in-hospital mortality and MACE.
- While long-term outcomes showed no significant differences, CR appears beneficial in the acute phase.
- The choice of revascularization strategy should be individualized, considering patient-specific factors and risk profiles.
Background:
In the elderly, acute coronary syndromes (ACS) are particularly challenging, especially with multivessel disease (MVD). Concerns about outcomes and limited evidence often lead to conservative treatment. While complete revascularization benefits in younger patients are well established, uncertainties persist for older individuals.
Methods:
A national multicenter, retrospective cohort study of 629 patients older than 75 with ACS and MVD was divided into two groups: complete revascularization (CR) and culprit-only (CO) revascularization. The in-hospital composite outcome of death and major adverse cardiovascular events (MACE) and the follow-up composite outcome of death and cardiovascular hospital admission were assessed.
Results:
Of 629 patients, 383 (66 %) were successfully revascularized: 254 (66 %) with CO revascularization and 129 (34 %) with CR. The mean age between groups was similar; in the CO group, it was 82 ± 5 years, while in the CR group, it was 81 ± 5 years (p = 0.4). The proportion of females was similar (42 % vs. 39 %). There was a higher ST-segment elevation myocardial infarction rate in the CO group (62 % vs 38 %, p < 0.01). CR was associated with a lower rate of in-hospital events (35 % vs 51 %, p = 0.025; OR 0.62 95 %CI [0.4-0.9]). Not only was there an association between CR and a lower number of in-hospital deaths (6 % vs. 19 %, p < 0.01; OR 0.3 95 %CI [0.15-0.67]) but also with lower in-hospital MACE (34 % vs. 49 % p = 0.02; OR 0.6 95 %CI [0.4-0.9]). During follow-up, complete revascularization was non-significantly associated with lower mortality (14 % vs. 15 %, p = 0.4), hospital admissions (22 % vs. 25 %, p = 0.2), and the composite outcome (35 % vs. 40 %, p = 0.2) compared with the culprit-only cohort. The survival curves of both groups were statistically similar (p = 0.16).
Conclusion:
In older patients with ACS and MVD, the ideal revascularization strategy is still to be determined. However, CR was associated with lower in-hospital deaths and MACE without significant difference in follow-up events, deaths, and hospital admissions. The choice of revascularization strategy should be carefully individualized and tailored considering patient-specific factors, clinical presentation, and overall risk profile.
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