Management of CAD in the Very Elderly

Ralph Brindis, MD, MPH, FACC, FSCAIVice President, American College of Cardiology

Senior Advisor for Cardiovascular Disease, Northern California KaiserClinical Professor of Medicine, University of California, San Francisco

6th Annual Oregon Cardiovascular SymposiumMay 30, 2009

Presenter Disclosure Information

Ralph Brindis, MD MPH FACC SCAI

The following relationships exist related to this presentation:

No relationships to disclose

Institute of Medicine Priorities for America

• We must overhaul the system to create We must overhaul the system to create care to ensure it is:care to ensure it is:

Safe, Timely, Equitable, Efficient, Evidence-based and Patient-centered

• Care should…• Be customized to patients’ needs and valuesBe customized to patients’ needs and values• Have the patient be the source of controlHave the patient be the source of control• Enable knowledge to be shared freelyEnable knowledge to be shared freely

Adams, K & Corrigan,JM. Priority Areas for National Action: Transforming Health Care Quality, IOM 2003

Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century

Defining Quality of ACS/CAD Care in Elderly

• TimelyTimely• Elderly present later and more ‘atypically’Elderly present later and more ‘atypically’

• Effective and safeEffective and safe• Both effectiveness and safety may change with pt ageBoth effectiveness and safety may change with pt age

• In particular, alterations in drug clearanceIn particular, alterations in drug clearance• Need adequate enrollment of elderly in clinical studies Need adequate enrollment of elderly in clinical studies

• Cost-effectiveCost-effective• Need to assure that benefits of ‘one more drug’ truly additiveNeed to assure that benefits of ‘one more drug’ truly additive• But, elderly’s higher risk usually leads to more CE careBut, elderly’s higher risk usually leads to more CE care

• EquitableEquitable• Once defined need to guard against ‘ageism’ in decisionsOnce defined need to guard against ‘ageism’ in decisions

• Patient centered, rationalPatient centered, rational• Need to individualize treatment for both pt’s clinical features and Need to individualize treatment for both pt’s clinical features and

health preferenceshealth preferences

The Graying of America

19951995Institute for the Future, Health and Health Care 2010 (2000)Institute for the Future, Health and Health Care 2010 (2000)

2030203020102010

90+80-8470-7460-6450-5440-4430-3420-2410-14< 10

90+80-8470-7460-6450-5440-4430-3420-2410-14< 10

Males FemalesMales Females

Millions12 8 4 0 4 8 12

Millions12 8 4 0 4 8 12

90+80-8470-7460-6450-5440-4430-3420-2410-14< 10

90+80-8470-7460-6450-5440-4430-3420-2410-14< 10

Males Females

Millions812 4 0 4 8 128

Millions12 4 0 4 8 12

Males Females Males Females

Millions12 8 4 0 4 8 12

Millions12 8 4 0 4 8 12

Males Females

Growth in US 80+ Population

0

5

10

15

20

25

1980 1990 2000 2010 2020 2030 2040 2050

Mill

ions

US Census Bureau 1992YEARYEAR

Management of the Elderly – Management of the Elderly – Life is Long !Life is Long !

A person who reaches age 65 has a life expectancy of A person who reaches age 65 has a life expectancy of 85 years85 years– What are the odds that he/she will live beyond age What are the odds that he/she will live beyond age

85? 85? – 50%50%

Consider a 65-year old coupleConsider a 65-year old couple– What is the likelihood that one or both will live to What is the likelihood that one or both will live to

age 97?age 97?– 25%25%

- How Not to Outlive Your Savings; MetLife Insurance 2004Wall Street Journal, Sept 30th, 2004

0

1020

30

4050

60

70

8090

100

20-24 25-34 35-44 45-54 55-64 65-74 75+

Men Women

Estimated Prevalence of Cardiovascular Estimated Prevalence of Cardiovascular Disease by Age and Gender in U.S. Disease by Age and Gender in U.S.

NHANES III

Per

cent

age

of P

opul

atio

n

The Magnitude of CVD in Older Persons

13

60

80

5

3441

0

20

40

60

80

100

US Pop. % Total MI % Total MIDeaths

% Age 65+Age 75+

AHA Consensus Group on Management of ACS in the Elderly

30-day mortality by age (continuous function)*STEMI Non-STEMI

**Based on clinical trials in approx 250,000 patients

Age 65 – 10% mortalityAge 65 – 5% mortality

Age 85 – 30% mortality Age 85 – 15% mortality

Challenges in Evidence Based Medicine

Age

Com

orbi

dity Community

Dis

ease

Sev

erity

60 68.3

Karen Alexander, DCRI

Advanced CADElderly

TrialsGuidelines

Management of Advanced CAD and the Management of Advanced CAD and the Elderly – Some Questions to ConsiderElderly – Some Questions to Consider

Is using appropriate anti-thrombotic and anti-ischemic Is using appropriate anti-thrombotic and anti-ischemic therapies (as suggested by the guidelines) appropriate therapies (as suggested by the guidelines) appropriate in the very elderly ?in the very elderly ?

What is the experience with an early cath strategy in the What is the experience with an early cath strategy in the elderly and those with complex CAD ?elderly and those with complex CAD ?

Have drug-eluting stents (DES) in PCI changed the Have drug-eluting stents (DES) in PCI changed the therapeutic landscape ?therapeutic landscape ?

Older CV Patients are “Different”• Reduced cardiovascular reserveReduced cardiovascular reserve

• Decreased vascular compliance Decreased vascular compliance • Increased myocardial stiffnessIncreased myocardial stiffness• -adrenergic responsiveness + impaired sinus node-adrenergic responsiveness + impaired sinus node

• Higher burden of comorbid illnessHigher burden of comorbid illness• ““frailness”frailness”

• Altered pharmacodynamics and pharmacokineticsAltered pharmacodynamics and pharmacokinetics• Decline in creatinine clearance, hepatic metabolismDecline in creatinine clearance, hepatic metabolism• Altered volume of distribution (adipose tissue)Altered volume of distribution (adipose tissue)

• Altered clotting mechanismsAltered clotting mechanisms• Reduced stem cell repairReduced stem cell repair

0

5

10

15

20

25

30

35

40

<65 65-74 75-84 85+

Stroke Renal Insuff CHF

Concomitant Co-morbid Illness in ACS in Older Persons

% o

f pop

ulat

ion

• ↓ ↓ Blood vessel integrity and response to injuryBlood vessel integrity and response to injury• Amyloid angiopathyAmyloid angiopathy

• PlateletsPlatelets• Turn over slower; older platelets are less ‘sticky’Turn over slower; older platelets are less ‘sticky’

• t-PA release enhanced with age (desmopressin)t-PA release enhanced with age (desmopressin)• ↑ ↑ Thrombin generation with ageThrombin generation with age

• ↑ ↑ Fibrinogen, ↑ Factors IX/XFibrinogen, ↑ Factors IX/X• D-dimer and inflammatory markers increased with age, D-dimer and inflammatory markers increased with age,

and frailtyand frailty

Altered Hemostasis and Inflammatory Markers

J Thrombosis and Hemostasis, Lakatta Circ 2003, Gudnason JThrombosis and Hemostasis

Patient Case

• 85 year old female, small NSTEMI, 3 vessel disease85 year old female, small NSTEMI, 3 vessel disease

• How to proceed? How to proceed? • Interventionalist – PCIInterventionalist – PCI• Surgeon – CABGSurgeon – CABG• General Cardiologist – medicationGeneral Cardiologist – medication• Patient - Are they even in the decision making process??Patient - Are they even in the decision making process??

Are We Practicing Geriatric Cardiology?Are We Practicing Geriatric Cardiology?

Traditional ApproachTraditional Approach• Treatment of HeartTreatment of Heart• ““Evidence-based Care”Evidence-based Care”• Few comorbidities, Unlimited reserveFew comorbidities, Unlimited reserve• Rx yields expected results Rx yields expected results • Outcomes Outcomes

– Death, MIDeath, MI

Geriatric ApproachGeriatric Approach• Treatment of HostTreatment of Host• ““Personalized Care”Personalized Care”• Multiple comorbidities, reserve variabilityMultiple comorbidities, reserve variability• Rx triggers complex effectsRx triggers complex effects• OutcomesOutcomes

– Death, MIDeath, MI– Physical FunctionPhysical Function– IndependenceIndependence– Cognitive AbilitiesCognitive Abilities

Parmley, JACC 1997; 29: 217-8Parmley, JACC 1997; 29: 217-8

““Yes and No”Yes and No”

Treating CAD in 2009Treating CAD in 2009

Patient with Patient with CAD CAD

undergoing undergoing CathCath

OMT AloneOMT Alone

CABG CABG SurgerySurgery

PCIPCIBMSBMS

DESDES

Outcomes:Outcomes:

Health Health StatusStatus

ComplianceCompliance

Can better informing Can better informing patients improve patients improve

compliance and safety?compliance and safety?

Goals of Coronary Revascularization

• Positively impact longevity/mortalityPositively impact longevity/mortality• Improvement in health status/symptomsImprovement in health status/symptoms• Ability to influence either is not equal for all Ability to influence either is not equal for all

clinical scenariosclinical scenarios• Longevity gains limited to selective patient Longevity gains limited to selective patient

scenarios - PCI vs CABGscenarios - PCI vs CABG

Complex Trade-offs• Clinical Questions:Clinical Questions:

• Optimal medical therapy?, PCI ?, DES/BMS?, CABG?Optimal medical therapy?, PCI ?, DES/BMS?, CABG?• 1, 2, or 3 vessel, LMCA involvement and % stenosis?1, 2, or 3 vessel, LMCA involvement and % stenosis?• Anatomy suitable?Anatomy suitable?• Severity of ischemia?Severity of ischemia?• Diabetic?Diabetic?• LV function and concomitant valvular disease?LV function and concomitant valvular disease?• Other co-morbidities?Other co-morbidities?• Prior PCI or CABG?Prior PCI or CABG?• Potential future elective non-cardiac surgery?Potential future elective non-cardiac surgery?• Patient ability for maintaining clopidogrel adherence?Patient ability for maintaining clopidogrel adherence?

Complex Trade-offs• Practice EnvironmentPractice Environment

• Is this case appropriate for PCI?Is this case appropriate for PCI?• How does this case impact interventionalist’s procedural volume ( >75/year)?How does this case impact interventionalist’s procedural volume ( >75/year)?• How does this case contribute to interventionalist’s mortality rate and other How does this case contribute to interventionalist’s mortality rate and other

performance measures?performance measures?• Is there Public Reporting of PCI outcomes?Is there Public Reporting of PCI outcomes?• How does this case impact referral cardiologist and the interventionist’s How does this case impact referral cardiologist and the interventionist’s

efficiency report?efficiency report?• Malpractice fears?Malpractice fears?• Fee for service “driver”Fee for service “driver”

Complex Trade-offs• SocietySociety

• Payment system rewards proceduresPayment system rewards procedures• Quantity not QualityQuantity not Quality

• Growth in medical costsGrowth in medical costs• Future – episode of care bundling & chronic disease management Future – episode of care bundling & chronic disease management

reimbursementreimbursement• PatientPatient

• Quality of lifeQuality of life• Impact of procedure and medicationsImpact of procedure and medications• Cost – co-pays and medicationsCost – co-pays and medications• Timing - impact on life events Timing - impact on life events • Patient preferencePatient preference

Changing State of the Science

• Literature for PCI, CABG, and medical therapy Literature for PCI, CABG, and medical therapy constantly changing over time with new RCTs and constantly changing over time with new RCTs and therapies – very challenging to compare and therapies – very challenging to compare and accurately assessaccurately assess

• AHRQ review (2006) of PCI and CABG found AHRQ review (2006) of PCI and CABG found roughly similar benefits and outcomes with various roughly similar benefits and outcomes with various caveats based on patient and type of outcome (LM, caveats based on patient and type of outcome (LM, LV dysfunction, 3 vessel, and DM favoring CABG)LV dysfunction, 3 vessel, and DM favoring CABG)

Dual Goals of Management of CAD Dual Goals of Management of CAD

Risk Reductionof Ischemic Events

Objective — Reduce the risk of recurrent

cardiovascular events and/or mortality

Control of risk factors to goal• Smoking (cessation)• Hyperlipidemia (LDL <70)• Hypertension (BP <130/85)• Diabetes (Hgb A1c <7)Pharmacologic therapy• ASA• Clopidogrel (post ACS/stent)• ACE/ARB• Beta-blocker• Statin

Treatment of Symptoms

Objective — Reduce symptoms to

increase exercise tolerance, and functional capacity

Revascularization• PCI or CABG

Anti-ischemic therapy• Beta-blockers• Nitrates• Calcium antagonists• Ranolazine

Selection of Strategy:Invasive Versus Conservative Strategy

An early invasive strategy is indicated in initially stabilized patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (I, A). Scores indicating elevated risk include combinations of the following:

– Recurrent angina/ischemia at rest or during low-level activities– Elevated cardiac biomarkers– New/presumably new ST-segment depression– Signs or symptoms of HF or new/worsening mitral regurgitation– High-risk findings from noninvasive testing– Hemodynamic instability– Sustained ventricular tachycardia– PCI within 6 months– Prior CABG– High risk score– LVEF <0.40

2007 ACC/AHA UA/NSTEMI Guideline Revision

Anderson JL, et al. J Am Coll Cardiol. 2007;50:652-726.

STRIVETM

Secondary Prevention: Additional Recommendations

ASA Clopidogrel β-blockers ACE inhibitors/ARBs Aldosterone blockade (↓EF) Statin

– Regardless of baseline LDL-C – Initiated prior to discharge– Goal LDL-C <100 mg/dL– LDL <70 mg/dL is reasonable

Treatment of triglycerides and non–HDL-C useful– If TG 200-499 mg/dL, non–HDL-C

should be <130 mg/dL– TG 500 mg/dL, fibrate or niacin

before LDL-C lowering to prevent pancreatitis

– Reasonable to encourage increased consumption of omega-3 fatty acids for risk reduction – IIb (B)

2007 ACC/AHA UA/NSTEMI Guideline Revision

Anderson JL, et al. J Am Coll Cardiol. 2007;50:652-726.

What the Guidelines Don’t SpecifyWhat the Guidelines Don’t Specify

Contraindications for therapiesContraindications for therapiesIdeal dosing of concomitant anti-thrombin and anti-platelet Ideal dosing of concomitant anti-thrombin and anti-platelet

therapiestherapiesHow to safely use invasive procedures together with multiple How to safely use invasive procedures together with multiple

anticoagulantsanticoagulantsHow to treat high-risk populationsHow to treat high-risk populations

– Advanced elderlyAdvanced elderly– Renal InsufficiencyRenal Insufficiency

4.9

9.8

3.95.7

0

5

10

15

Age<65 Age>/=65

6.5

13.6

6.18.8

0

5

10

15

20

25

Age<65 Age>/=65

Invasive vs. Conservative Management of UA/NSTEMI in TACTICS-TIMI 18 Stratified by Age

30 Days30 Days 6 Months6 Months

OR=0.61OR=0.61*p=0.018*p=0.018

**

OR=0.94OR=0.94p=0.79p=0.79

OR=0.56OR=0.56*p=0.019*p=0.019

OR=0.78OR=0.78p=0.37p=0.37

(%)

(%)

Death or Non-Fatal MI

**

00 0.5 0.5 1 1 1.5 1.5 2.0 2.0INV Better CONS Better

CONCON INV INV OROR(%)(%) (%) (%)

4.8 4.8 5.0 5.0 1.071.07

9.19.1 7.6 7.6 0.820.82

10.310.3 7.8 7.8 0.730.73

21.621.6 10.810.8 0.44*0.44*

**p=0.016p=0.016

Age GroupAge Group (n) (n)

Age Age 55 55 (716)(716)

Age >55-65Age >55-65 (614)(614)

Age >65-75Age >65-75 (612)(612)

Age > 75Age > 75 (278)(278)

Death, MI at 6 MonthsDeath, MI at 6 Months

Efficacy of Invasive Strategy Across Age SubgroupsEfficacy of Invasive Strategy Across Age Subgroupsin TACTICS-TIMI 18in TACTICS-TIMI 18

1.66.4 6.5

3.6 4.79

16.6

6.5

0

10

20

30

40

50

(%)

CONCON

Major Bleeding According to Treatment Strategy Major Bleeding According to Treatment Strategy Stratified by Age Group in TACTICS-TIMI 18Stratified by Age Group in TACTICS-TIMI 18

INVINV

5555 >55-65 >55-65 >65-75 >65-75 >75 >75 (716)(716) (614)(614) (612)(612) (278) (278)

OR=2.25OR=2.25 OR=0.73 OR=0.73 OR=1.38 OR=1.38 OR=2.55 OR=2.55 p=0.10p=0.10 p=0.367 p=0.367 p=0.25 p=0.25 *p=0.009 *p=0.009

Age Group:Age Group: (n)(n)

Therapeutic Implications of the TACTICS-Therapeutic Implications of the TACTICS-TIMI 18 Results Stratified by AgeTIMI 18 Results Stratified by Age

Absolute RR Relative RRAbsolute RR Relative RR NNTNNT

per 1000 Pts (%)per 1000 Pts (%)

Age < 65 Age < 65 4 4 6 6 250 250Age Age 65* 65* 4848 3939 2121

Age Age 55 55 -2-2 -7-7 -- --Age >55-65Age >55-65 1515 1818 6767Age >65-75Age >65-75 2525 2727 4040Age >75*Age >75* 108 108 5656 9 9

*p < 0.05 , others p = NS*p < 0.05 , others p = NS

Death or Nonfatal MI at 6 moDeath or Nonfatal MI at 6 mo

Survival Free of Death from Any Cause and Myocardial Infarction

Number at RiskMedical Therapy 1138 1017 959 834 638 408 192 30PCI 1149 1013 952 833 637 417 200 35

Years0 1 2 3 4 5 6

0.0

0.5

0.6

0.7

0.8

0.9

1.0

PCI + OMT

Optimal Medical Therapy (OMT)

7

Hazard ratio: 1.0595% CI (0.87-1.27)P = 0.62

Stable Angina

Conclusions

• STABLE CAD: PCI as an initial management strategy in the setting of stable CAD has not been shown to reduce the incidence of Death or MI or mortality• PCI has not been shown to prolong life expectancy• PCI added to OMT was more effective in reducing ischemia and improving angina than OMT, particularly in patients with moderate-to-severe pre-rx ischemia• Most patients will have improvement in anginal status whether treated initially with PCI+OMT or OMT alone

Implications

• Reinforces existing ACC/AHA clinical practice guidelines, which state that PCI can be safely deferred in patients with stable CAD, even in those with extensive, multivessel involvement and inducible ischemia, provided that intensive, multifaceted medical therapy is instituted and maintained

• Optimal medical therapy and aggressive management of multiple treatment targets without initial PCI can be implemented safely in the majority of patients with stable CAD—two-thirds of whom may not require even a first revascularization during long-term follow-up

Rates of Death or MI by Extent of Rates of Death or MI by Extent of Ischemia Reduction Ischemia Reduction

24.7%

13.4%

0%

10%

20%

30%

40%

RR = 0.47 (95% CI 0.23-0.95)

Shaw LJ et al. Circulation 2008;117:1283-91

Ischemia Reduction

≥5%

Ischemia Reduction

<5%

CABG vs PCI in Diabetics CABG vs PCI in Diabetics Mortality in Pts with Multivessel DiseaseMortality in Pts with Multivessel Disease

• Significant survival benefit w/CABG over 4 years

• Benefit somewhat attenuated and highly uncertain at 6.5 yrs

Time-Dependent Meta-Analysis

Hoffman SN et al. JACC 2003;41:1293-304

Changing State of the Science

SYNTAX 2008SYNTAX 2008Randomization between CABG versus PCI with Randomization between CABG versus PCI with

DES in patients with Triple-Vessel and/or Left DES in patients with Triple-Vessel and/or Left Main DiseaseMain Disease

• Not powered enough to make true inferences Not powered enough to make true inferences among the very elderlyamong the very elderly

• Only one year follow-upOnly one year follow-up

71% enrolled (N=3,075)

All Pts with de novo 3VD and/or LM disease (N=4,337)

Treatment preference (9.4%) Referring MD or pts. refused

informed consent (7.0%) Inclusion/exclusion (4.7%) Withdrew before consent (4.3%) Other (1.8%) Medical treatment (1.2%)TAXUS

n=903PCI

n=198CABG

n=1077CABGn=897

no f/un=428

5yr f/un=649

PCIall captured w/

follow up

CABG2500

750 w/ f/uvsvs

Total enrollment N=3075

Stratification: LM and Diabetes

Two Registry ArmsRandomized Armsn=1800

Two Registry ArmsN=1275

Randomized ArmsN=1800

Heart Team (surgeon & interventionalist)

PCIN=198

CABGN=1077

Amenable for only one treatment approach

TAXUS*

N=903 CABGN=897 vsvs

Amenable for bothtreatment options

Stratification: LM and Diabetes

LM33.7%

3VD66.3%

LM34.6%

3VD65.4%

DM 28.5%

Non DM71.5%

NonDM71.8%

DM28.2%

23 US Sites62 EU Sites +SYNTAX Trial DesignSYNTAX Trial Design

**TAXUS ExpressTAXUS Express

PatienPatient 1t 1

PatienPatient 1t 1

PatienPatient 2t 2

PatienPatient 2t 2

SYNTAX SCORE 21SYNTAX SCORE 21 SYNTAX SCORE 52SYNTAX SCORE 52

LCx 70-90%LCx 70-90%

LAD 70-90%LAD 70-90%

RCA2 70-90%RCA2 70-90%

RCA3 70-90%RCA3 70-90%

LM 99%LM 99%

LCx 100%LCx 100%

LAD 99%LAD 99%

RCA 100%RCA 100%

There is ‘3-vessel disease’ and ‘3-vessel disease’There is ‘3-vessel disease’ and ‘3-vessel disease’

SYNTAX Primary EndpointSYNTAX Primary EndpointRandomized trialRandomized trial

The primary clinical endpoint is the 12 Month major Cardiovascular or Cerebrovascular event rate

(MACCE *)MACCE is defined as:

All cause DeathCerebrovascular Accident (CVA/Stroke)Documented Myocardial Infarction (ARC definition)Any Repeat Revascularization (PCI and/or CABG)

*ARC MACCE definition Circ 2007; 115:2344-2351

12 Month Subgroup MACCE Rates

All LMN=705

LM+1VDN=138

LM isolatedN=91

LM+2VDN=218

LM+3VDN=258

Patie

nts (

%)

3VD (All)N=1095

CABG TAXUS

Conclusions: Conclusions:

In the randomized SYNTAX cohort, there were comparable overall safety outcomes (Death, CVA, MI,) in CABG and PCI patients at 12 months (7.7 vs. 7.6 %).There was a significantly higher rate of revascularization in the PCI group (13.7 vs. 5.9 %), and a significantly higher rate of CVA in the CABG group (2.2 vs. 0.6 %).Overall MACCE in the PCI group was higher (17.8 vs.12.1 %) due to an excess of redo revascularization compared with CABG.Per protocol rates of symptomatic graft occlusion and stent thrombosis were similar.The SYNTAX score will help stratify patients for the appropriate revascularization option.

CABG or PCI for LMCA in OctogenariansCABG or PCI for LMCA in Octogenarians

249 pts >80 yo 249 pts >80 yo non-randomized non-randomized - CABG or PCI- CABG or PCI2 year follow up2 year follow upPCI pts- older, higher Creatinine, lower ej.fx., higher PCI pts- older, higher Creatinine, lower ej.fx., higher

EuroSCORE and more ACS presentationEuroSCORE and more ACS presentationDES 48% of PCI patientsDES 48% of PCI patientsDeath/MI 35% PCI, 30% CABGDeath/MI 35% PCI, 30% CABGMACCE free survival: 57% PCI vs. 65% CABGMACCE free survival: 57% PCI vs. 65% CABGEuroSCORE independent predictor of MACCEEuroSCORE independent predictor of MACCE

Rodes-Cabau, Circulation 2008;118:2374-2381.

CABG or PCI for LMCA in OctogenariansCABG or PCI for LMCA in Octogenarians

PCIPCI : 6.7% 30 day mortality, 12.5% 30 day MI : 6.7% 30 day mortality, 12.5% 30 day MICABGCABG : 8.3% 30 day mortality, 17.2% 30 day MI : 8.3% 30 day mortality, 17.2% 30 day MI30 day MACCE30 day MACCE : 18% PCI vs 28% CABG : 18% PCI vs 28% CABGCABG - higher new onset atrial fibrillation, renal CABG - higher new onset atrial fibrillation, renal

failure, bleeding requiring transfusions, longer failure, bleeding requiring transfusions, longer hospital stay.hospital stay.

Rodes-Cabau, Circulation 2008;118:2374-2381.

Death or MI and MACCEDeath or MI and MACCE

Figure 1. Risk of cardiac death or MI (A) and Figure 1. Risk of cardiac death or MI (A) and MACCE (B) at a mean follow-up of 23 months MACCE (B) at a mean follow-up of 23 months in the whole cohort and in the subgroups in the whole cohort and in the subgroups identified according to the quartiles of the identified according to the quartiles of the propensity score as a function of treatment: propensity score as a function of treatment: PCI vs CABG. Values are expressed as 95% PCI vs CABG. Values are expressed as 95% CI.CI.

PCI vs CABG for LMCA in Very Elderly (>80)

Rodes-Cabau, Circulation 2008;118:2374-2381.

Cardiac Death or MI-freeCardiac Death or MI-free Survival Curves Survival Curves

Figure 2. Cardiac death– or MI-free Figure 2. Cardiac death– or MI-free survival curves (A) and MACCE-survival curves (A) and MACCE-free survival curves (B) free survival curves (B) constructed with Cox constructed with Cox regression analysis adjusted for regression analysis adjusted for propensity scorepropensity score

PCI vs CABG for LMCA in Very Elderly (>80)

Rodes-Cabau, Circulation 2008;118:2374-2381