from Treating the Whole Woman, a Penn Medicine Media Seminar at Pennsylvania Hospital, Philadelphia
Medical options narrow once people become nonagenarians.
This week, a Lancet article reported results from a meta-analysis of 10 randomized coronary-revascularization trials that compared percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The new analysis showed that CABG led to better survival as people got older. Among patients 65 and older, CABG cut follow-up mortality by 18%, compared with PCI.
But a finding like this has limited applicability to real-world practice, especially for patients who are substantially older, said Dr. Charles R. Bridges, chief of cardiovascular surgery at Pennsylvania Hospital.
“Most patients [who need revascularization] are excluded from randomized studies because they can only enroll patients who are ideal candidates for either strategy,” said Dr. Bridges, who has done extensive reviews of cardiac surgery in nonagenarians. “If a patient has a coronary artery that is 100% occluded, it can’t be treated by PCI. If a patient has multiple lesions that would require many stents, they’re usually treated by CABG. But patients with single vessel disease usually go for PCI.
“There aren’t many cases where it’s a toss-up” between the two alternatives.
All of this doesn’t hide the fact that when PCI is feasible, it’s the treatment that most patients and their physicians prefer, especially for the very old. Dr. Bridges acknowledged this despite his inherent predisposition toward coronary surgery.
“If it’s technically feasible to do PCI, then that’s generally what’s done. CABG is the best option mostly when PCI isn’t feasible,” Dr. Bridges said.