Surgery for angina in the elderly provides long-term mortality

Aug 30 2004

Elderly people who undergo surgery or angioplasty to treat chest pain fare just as well long-term as those treated with medication, researchers report in Circulation: Journal of the American Heart Association.

This is the first long-term, randomized, prospective study of chronic angina (chest pain) treatment outcomes among people age 75 and older, researchers said.

"Our results show that long-term mortality is similar in invasively treated patients and those treated with optimal drug therapy. Chest pain relief and improved quality of life are also similar, but invasively managed patients reach this benefit earlier," said Matthias Pfisterer, M.D., professor and head of the department of cardiology, University Hospital, Basel, Switzerland.

Pfisterer is the lead investigator of this Trial of Invasive versus Medical Therapy in Elderly Patients (TIME).

Many studies have shown that coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) – also called angioplasty – provide good symptom relief and outcomes in younger patients. However, physicians often choose the more conservative medication therapy approach for older patients due to concerns that the risks of invasive procedures might outweigh their benefits, he explained.

In the study, 91.5 percent of patients treated invasively and 95.9 percent of those on medical therapy were alive at six months. Survival was still similar after 5.1 years: 70.6 percent for patients treated with the invasive approach and 73 percent for those treated with medication. Demographics of the U.S. population make data on this subject extremely import to clinicians.

"People older than 75 years represent the fastest-growing population segment in the western world, and heart and blood vessel disease is the most prominent cause of death and disability in this age group," Pfisterer said.

The 301 patients (average age 80) studied suffered from angina, which is caused when fatty deposits (atherosclerotic plaque) in the coronary arteries restrict blood flow to the heart. Angina symptoms are especially noticeable during exertion.

Twenty percent of the patients had chest pain when climbing stairs, nearly half experienced it when walking on level ground and one third had chest pain even at rest.

Patients were assigned randomly to one of two groups – 1) treatment with CABG or PCI and 2) treatment with medication alone. One hundred fifty-three patients were assigned to CABG or PCI; 148 received optimal medication. Optimal medication included aspirin, statins and angiotensin-converting enzyme (ACE) inhibitors.

The present study examined data on the patients from the end of the first year after they were randomized for an average of four years.

All those in the invasive group who were considered good candidates for those procedures received them at the start of the study. The rest were treated with medication. Subjects in the medically treated group in whom medication failed to relieve symptoms received an invasive procedure if their coronary anatomy was suitable for the procedure.

Quality of life – defined in this study as freedom from heart attacks, cardiac hospitalization or revascularization by CABG or PCI – was 39 percent for the invasively treated patients compared to 20 percent for the medication therapy group. In addition, the medically treated patients required more anti-anginal drugs throughout the study.

Medically treated patients also experienced more non-fatal events – mostly re-hospitalizations for chronic angina that failed to respond to medication. In fact, 43 percent of all medically treated patients continued to experience chronic chest pain and had one of the invasive procedures, usually within the first six months of the study.

Factors associated with mortality included increased age (over age 80), prior heart failure, an ejection fraction (measure of the heart's pumping ability) of less than 45 percent, at least two co-diseases such as peripheral vascular disease, renal failure, chronic pulmonary disease and not receiving revascularization within the first year.

"Patients with chronic angina may be managed with drug therapy or with an invasive strategy," Pfisterer said. "Catheterization is advisable if symptoms don't respond to drug treatment and even in elderly patients a procedure should then be done without fear of higher mortality."

http://www.americanheart.org/