ABSTRACT
BACKGROUND: Balancing risks and benefits of revascularization in elderly patients with multivessel coronary artery disease (CAD) is challenging. The appropriate revascularization strategy for elderly patients with multivessel CAD is unclear. METHODS: We used the Duke Databank for Cardiovascular Disease to identify patients aged 75 years or more who had multivessel disease and treatment with percutaneous coronary intervention or coronary artery bypass graft surgery (CABG) within 30 days of the index catheterization between October 1, 2003, and June 30, 2013. The primary outcome was a composite of all-cause death, myocardial infarction, and coronary revascularization through latest follow-up. Associations between bare-metal stents (BMS), drug-eluting stents (DES), CABG, and outcomes were determined using multivariable Cox proportional hazards modeling, adjusting for potential confounders with CABG as the reference. Comparisons between BMS and DES were done using BMS as the reference. RESULTS: We identified 763 patients who met the criteria (BMS, n = 202; DES, n = 411; CABG, n = 150). The median age was 79 years (interquartile range, 76 to 82), and the median follow-up was 6.28 years. After adjustment, both BMS and DES were associated with a higher risk of the primary outcome. The BMS versus CABG hazard ratio was 1.58 (95% confidence interval: 1.15 to 2.19, p = 0.01). The DES versus CABG hazard ratio was 1.45 (95% confidence interval: 1.08 to 1.95, p = 0.01). The adjusted hazard ratio for DES versus BMS (0.92, 95% confidence interval: 0.71 to 1.19, p = 0.51) was not statistically significant. CONCLUSIONS: In this single-center analysis of 763 elderly patients with multivessel disease, CABG was associated with the best overall clinical outcomes, but was selected for a minority of patients. An adequately powered, randomized trial should be considered to define the best treatment strategy for this population.
Subject(s)
Coronary Artery Bypass/standards , Coronary Artery Disease/surgery , Percutaneous Coronary Intervention/standards , Practice Guidelines as Topic , Aged , Coronary Angiography , Coronary Artery Disease/diagnosis , Female , Follow-Up Studies , Humans , Male , Retrospective Studies , Risk Factors , Stents , Time Factors , Treatment OutcomeSubject(s)
Abortion, Therapeutic , Aortic Aneurysm, Thoracic/complications , Aortic Coarctation/complications , Aortic Dissection/complications , Hypertension, Pregnancy-Induced/etiology , Adult , Black or African American , Aortic Dissection/diagnostic imaging , Aortic Dissection/etiology , Aortic Dissection/surgery , Angiography , Aortic Aneurysm, Thoracic/diagnostic imaging , Aortic Aneurysm, Thoracic/etiology , Aortic Coarctation/diagnostic imaging , Electrocardiography , Female , Humans , Hypertension, Pregnancy-Induced/diagnosis , Hypertension, Pregnancy-Induced/therapy , Hypertrophy, Left Ventricular/diagnostic imaging , Magnetic Resonance Imaging , Pregnancy , Risk Assessment , Systolic Murmurs/diagnosis , UltrasonographyABSTRACT
A 54-year-old African American male with no medical history presented to an urgent care clinic with signs and symptoms of new-onset congestive heart failure. There was an initial concern for congestive heart failure secondary to an ischemic etiology as an echocardiogram revealed a depressed ejection fraction. However, a left heart cardiac catheterization did not demonstrate any significant coronary disease. As a loud bruit was auscultated over the right base of the patient's neck, he underwent a carotid duplex ultrasound revealing a fistula between the right common carotid artery (CCA) and the right internal jugular vein (IJV). A diagnosis of high-output heart failure secondary to a large arteriovenous (AV) fistula was made, and the patient underwent ligation and repair of the fistula with resolution of symptoms of congestive heart failure.
