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Coronary revascularization after myocardial infarction in the very elderly: outcomes and long-term follow-up
H M Krumholz1, D E Forman, R E Kuntz
1Charles A. Dana Research Institute, Boston, Massachusetts.
Insights
Coronary revascularization improved survival and quality of life for very elderly patients after acute myocardial infarction. Despite risks, selected patients tolerated procedures well, returning to independent living with better long-term outcomes.
Area of Science:
- Cardiology
- Geriatric Medicine
- Interventional Cardiology
Background:
- Acute myocardial infarction (AMI) in very elderly patients (≥80 years) presents unique management challenges.
- Outcomes of invasive cardiovascular procedures like coronary revascularization in this demographic are not well-established.
Purpose of the Study:
- To evaluate the outcomes of very elderly patients undergoing coronary revascularization during hospitalization for AMI.
- To assess survival, quality of life, and functional status at least one year post-discharge.
Main Methods:
- Retrospective cohort study including 93 patients (≥80 years) hospitalized with AMI between 1985-1990.
- Patients underwent cardiac catheterization before discharge; subgroups included angioplasty (n=41), coronary artery bypass surgery (n=18), and medical therapy (n=34).
- Outcomes measured included survival, quality of life, and functional status at least 1 year post-discharge.
Main Results:
- Patients undergoing revascularization (angioplasty or surgery) reported higher rates of good/excellent quality of life and self-care ability compared to medical therapy.
- One-year mortality rates were 24% for angioplasty, 6% for surgery, and 44% for medical therapy.
- Coronary revascularization was associated with increased survival (hazard ratio, 0.42) after adjusting for confounding factors.
Conclusions:
- A select group of very elderly patients with complicated AMIs can tolerate coronary revascularization, avoid major complications, and achieve good long-term outcomes.
- Results suggest potential survival benefits of revascularization in this population.
- Further research is needed to definitively establish the role of coronary revascularization in very elderly patients with AMI due to study limitations.
Objective:
To determine the outcome of very elderly patients who had coronary revascularization during hospitalization for an acute myocardial infarction.
Design:
Retrospective cohort study.
Setting:
Community-based tertiary-care teaching hospital.
Patients:
A total of 1215 consecutive patients 80 years and older were hospitalized with a myocardial infarction between 1985 and 1990. The study sample included all 93 patients (8%) who had cardiac catheterization before discharge and had not been excluded from study because of the following: severe valvular disease, absence of significant coronary disease, or death before a decision about revascularization could be made.
Measurements:
Survival, quality of life, and functional status at least 1 year after discharge.
Results:
After catheterization, 41 patients had angioplasty, 18 had coronary artery bypass surgery, and 34 did not have revascularization. Among the patients alive at discharge, those who had revascularization had a high likelihood of achieving a good or excellent quality of life (angioplasty, 86% [31 of 36]; surgery, 89% [16 of 18]; medical therapy, 44% [11 of 25]) and of being able to care for themselves (angioplasty, 89% [32 of 36], surgery, 89% [16 of 18], medical therapy, 52% [13 of 25]). Mortality rates at 1 year were 24% (95% CI, 15% to 47%) for the angioplasty group, 6% (CI, 0% to 27%) for the surgery group, and 44% (CI, 27% to 62%) for the medical therapy group. In a Cox proportional hazards model that adjusted for clinical, demographic, hemodynamic, and anatomic differences between the groups, the performance of coronary revascularization was associated with increased survival (hazard ratio, 0.42; CI, 0.18 to 0.98).
Conclusions:
A small percentage of very elderly patients with complicated acute myocardial infarctions, selected by their physicians for invasive cardiovascular procedures, can tolerate these procedures, avoid serious complications, return to independent living, and have excellent probability of survival. Although our results suggest that coronary revascularization may have benefited these patients, the study design did not permit definite conclusions, and future studies are needed to resolve this important question.
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