Patient age & benefit of PCI vs CABG: PCI better outcomes for younger patients, CABG better outcomes for older patients

Image: PD/NIH

PCI =  Percutaneous Intervention, CABG: Coronary Artery Bypass Graft 

Key study points:

1. A pooled analysis of 10 clinical trials with 7,812 patients showed a shift in the comparative effectiveness of CABG versus PCI with age.

2. Older patients experienced lower rates of mortality and a composite of death and myocardial infarction with CABG, whereas younger patients fared better with PCI.

Primer: In patients with multivessel coronary artery disease, the decision between percutaneous intervention (PCI) versus open cardiac surgery (CABG) can be challenging, with extent of disease, vascular complexity, comorbidities, and ability to tolerate surgery all under consideration, often pointing in opposing therapeutic directions.

Overall, studies to date show similar mortality rates between PCI and CABG. However, this study found significant differences when results were stratified by age: pooling outcomes from 10 randomized trials with regards to patient age demonstrated a decreasing risk of major cardiac events in CABG compared to PCI as patients got older. This difference by age persisted among the subgroup of patients with diabetes, and with both metal stents and balloon angioplasty.

This [retrospective] study: 10 randomized trials comparing CABG and PCI in patients with multivessel disease were pooled, with age analyzed as a continuous variable for a primary outcome of all-cause mortality and secondary outcomes of a composite of death or myocardial infarction, need for repeat revascularization, and angina at 1 year. Overall, these 10 trials found no difference in mortality rates between PCI and CABG. When the patient population was stratified by age, however, CABG to PCI hazard ratios were 1.23 for the youngest group of <56.2 years, 0.89 for the middle group 56.3 to 65.1 years, and 0.79 for the oldest group. The interaction on age with the relative risk over data points had a P<0.01. Rates of angina after 1 year and repeat vascularization were reduced to a similar extent by CABG compared to PCI in all age groups; there was no differential effect by age.

In sum: The relative risk of PCI is higher in older patients whereas the relative risk of CABG is higher in younger patients. Of note, given the low number of patients over 75 years of age, the study was not appropriately powered to assess risk in the oldest of patients. There were also many secondary variables that were not included in the study (extent of disease, renal function, anemic, etc.) and therefore cannot be excluded as potential confounders. Finally, the study did not include the most recent PCI trials that utilized drug-eluting stents. Upon review of the literature, the study authors did not believe that inclusion of drug-eluting stents would change the increasing risk of PCI with age, but additional studies would be needed to confirm.

Click to read the article in the Journal of the American College of Cardiology

More from this author: CABG demonstrates better rates of survival versus PCI in diabetic patients: FREEDOM trial, Modifying mitral valve structure concurrently with coronary bypass helps post-MI patients optimize cardiac function and improve functional status

By [GS] and [AH]

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