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Coronary Revascularization after Myocardial Infarction in the Very Elderly: Outcomes and Long-Term Follow-up
- Harlan M. Krumholz, MD;
- Daniel E. Forman, MD;
- Richard E. Kuntz, MD;
- Donald S. Baim, MD; and
- Jeanne Y. Wei, MD
- From the Charles A. Dana Research Institute and Harvard Medical School, Boston, and the GRECC Brockton/West Roxbury Veterans Affairs Medical Center, West Roxbury, Massachusetts. Requests for Reprints: Harlan M. Krumholz, MD, Section of Cardiovascular Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510-8056. Acknowledgments: The authors thank Drs. Lee Goldman, Daniel Levy, Gottlieb C. Friesinger II, Ralph Horwitz, Barry L. Zaret, and Lawrence S. Cohen for their comments on the manuscript; and Dr. Charles Safran for his help with ClinQuery. Grant Support: In part by the National Heart, Lung, and Blood Institute Cardiovascular Research Training Grant HL-07374.
Abstract
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.
- Copyright 2004 by the American College of Physicians
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