Catheterization and Cardiovascular Interventions | 2021
We can, but should we?
Abstract
In recent years, percutaneous coronary intervention (PCI) in the treatment of left main disease has emerged as a viable alternative to coronary artery bypass grafting (CABG). With the publication of three large-scale randomized trials (SYNTAX, NOBLE, and EXCEL) the European guidelines were updated in 2018 to recommend PCI as an alternative to CABG in the treatment left main coronary artery disease with a class 1 recommendation in low SYNTAX and a class 2a recommendation intermediate SYNTAX anatomic complexity scores. The first question that must always come to mind before changing any paradigm, in this case nonsurgical management of left main or bifurcation disease in the elderly, is “should we?” That being addressed already, the next question was the subject of the preceding report, “can we?” Conrotto and his co-authors in the preceding report from a large Italian registry say we can, with some realities discussed, but without in-hospital major adverse cardiac events (MACE) part of their report. Of course, they are not alone in pursuing this largely successful approach to their patients, and are commended for looking at how the particularly elderly fare after hospital discharge. As always with a retrospective registry, there are large differences in the groups being examined, and this report is no different. Of the demographic and procedural characteristics, 19/35 were statistically different, not including whether the thin-strutted stents had biodegradable polymers or not. In addition, there is not a breakdown of what number of the left main PCIs were at the bifurcation versus a single stent need for the body of the artery in the two. It should be noted that there was no mention of circulatory support in any of the patients in the report; this is remarkable, and a testament to the prowess of the many investigators. Final kissing balloons has become more the standard of late, but was left to individual operators and any significant differences may or may not have contributed to the outcomes reported. The preceding report highlights the difference between CV death and all-cause death, the latter perhaps more real for octogenarians since many more have concomitant diseases, for example, renal disease in 38% versus 16% in the younger cohort in this report. While cardiovascular mortality was no different at their follow-up point, 15 months, overall mortality, and MACE were significantly higher. As the authors note, the increased all-cause mortality may be a function of advanced age, and increased comorbidity-associated complications, and this reality will likely influence longer-term outcomes. A mid-term report of 15 months raises the question posed earlier, “should we” if we have other options, be it medical or surgical. Even for an octogenarian these days, 5-year outcomes would probably hold more weight regarding options. Cardiologists are already treating an increasing number of octogenarians as the proportion of patients aged >80 years continues to increase. In past reports, older age was shown to be predictive of lower use of cardiac catheterization. In our experience, this appears less evident but may still be true in various practices and countries. Management decisions in older patients is challenging, as increasing age is a predictor of adverse events, is a predictor of all-cause mortality as demonstrated in this study, and since older adults are underrepresented in randomized clinical trials, it remains unclear whether results of these trials can be extrapolated to the elderly population. Fourteen years ago, there was a not too dissimilar editorial comment written for the Journal on the subject the super-elderly. The clinical questions raised then are the same today, but our available technology has markedly improved and with that target lesions are more treacherous. The good news is that success rates remain high, but still the unanswered question remains, “Are we doing what is best and most cost-effective treatment for these patients?” The results of this study are in line with other current literature demonstrating that age alone should not exclude elderly patients from percutaneous revascularization. One should consider other factors, such as frailty, Received: 15 March 2021 Accepted: 16 March 2021