Abstract
Introduction: The optimal revascularization strategy for left main disease in very elderly patients is unclear given under-representation in randomized trials. Therefore, we sought to compare percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for left main disease in very elderly patients presenting with acute myocardial infarction (AMI). Methods: Retrospective study of patients aged ≥ 80 years undergoing invasive coronary angiography (ICA) for AMI at Kaiser Permanente Los Angeles Medical Center between June 2009 and February 2019. Patients were grouped by treatment decision: PCI, CABG, or medical therapy. Inverse Probability Treatment of Weighting (IPTW) was used to balance baseline characteristics. All-cause mortality and non-fatal myocardial infarction (MI) was evaluated. Results: A total of 172 patients (average age 84.4 ± 3.6 years, 37% female) were analyzed. Of these 54 (31.4%) underwent PCI, 67 (39%) underwent CABG, and 51 (29.7%) were treated with medical therapy. Compared to CABG, the PCI group was significantly older, with more history of CAD, COPD, previous CABG, and previous PCI. Median follow-up was 22.4 months (interquartile range 5.1-46.8 months). After IPTW adjustment, there were no differences in mortality between PCI vs CABG (Hazard Ratio [HR] 1.40, 95% Confidence Interval [CI] 0.97-2.01), but an increase in non-fatal MI with PCI (HR 2.6, 95% CI 1.02-6.69). Both PCI and CABG reduced mortality (PCI: HR 0.46, 95% CI 0.32-0.66; CABG: HR 0.71, 95% CI 0.52-0.96) and non-fatal MI (PCI: HR 0.22, 95% CI 0.11-0.41; CABG: HR 0.09, 95% CI 0.4-0.23) compared to medical therapy. Conclusion: In very elderly patients with left main disease presenting with AMI, there was no difference in mortality between PCI and CABG, but an increased risk for non-fatal MI with PCI. However, both PCI and CABG were superior to medical therapy. Either revascularization strategy may be reasonable in this population.
Published Version
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