Clinical Manifestations Of Complex Coronary Heart Disease In The Elderly And The Impact Of Different Revascularization Strategies On Long-term Prognosis

Bacground and significance:Coronary atherosclerotic heart disease is one of the leading bad effects for the elderly.Elderly patients often have many diseases,such as hypertension,diabetes mellitus,and dyslipidemia,and various factors,such as the debilitating body condition,atypical clinical manifestationsm,and reduced organ function of elderly patients,increase the treatment risk of coronary heart disease.Because of the complexity of the condition,previous studies mostly ignored the elderly patients.The CAMI study demonstrated that early reperfusion therapy especially with primary PCI in elderly patients with ACS is safe and effective and significantly reduces mortality compared with no reperfusion therapy group.At present,whether the degree of revascularization by PCI in elderly patients with multivessel coronary artery disease has an impact on th prognosis of patients has rarely been reported.More relevent clinical data of large-scale Chinese elderly patients with CHD are lacking.Therefore,the aim of this study was to investigate the effect of the degree of revascularization on the prognosis of elderly patients with multivessel coronary disease by analyzing the results of 2 year follow up in a single center,large sample of elderly patients with coronary artery disease who underwent PCI,and to provide a reference for clinical treatment decisions.Objectives:To compare the effects of different revascularization strategies on long-term prognosis in elderly patients with multi-vessel coronary artery disease.Methods:From 2013 January to December,1152 consecutive patients undergoing any PCI in Fuwai Hospital with multi-vessel coronary artery disease aged 60 and above were evaluated,and excluding patients with a previous history of coronary artery bypass graft surgery,single coronary artery disease patients.A 2 year follow up was taken for the study group patients.The study primary endpoint was defined as:all-cause death,myocardial infarction,revascularization,stroke and stent thrombosis.Comparisons of baseline data were performed using t-tests,Chi square tests,and propensity score mating was used to adjust for imbalances at baseline.The Kaplan-Meier method was used to compare the incidence of end-point events.We grouped according to ages,60-64 years old group(n=465 cases),65-69 years old group(n=315 cases),70-74 years old group(n=223 cases)and≥75 years old group(n=149 cases).Then used multivariable Cox regression method for survival analysis.The primary endpoints were defined as all-cause death,myocardial infarction,revascularization,stroke,and stent thrombosis.Results:535(46.4%)patients underwent complete revascularization.9.5%of patients with complete revascularization had major adverse cardiovascular and cerebrovascular events(MACCE),and 14.7%of patients with incomplete revascularization had MACCE events.Multivariate Cox survival analysis showed that MACCE in the complete revascularization group was significantly lower than that in the incomplete revascularization group(HR=0.697,95%CI 0.493～0.986,P=0.041).Subgroup analysis showed that ACS group(HR=0.647,95%CI:0.419～0.998,P=0.049)and double-vessel coronary disease group(HR=0.386,95%CI:0.158～0.946,P=0.037)benefited more from complete revascularization.However,stable coronary heart disease group did not benefit from complete revascularization(HR=0.774,95%CI:0:434～1.379,P=0.384).Conclusions:Complete revascularization in patients with multi-vessel coronary artery disease older than 60 years of age is superior to incomplete revascularization.ACS patients benefit more from complete revascularization.Stable coronary heart disease patients do not benefit from complete revascularization.Objectives:To explore the long-term prognosis factors between different types of elderly patients with acute coronary syndrome(ACS)over 60 years old undergoing percutaneous coronary intervention(PCI).Methods:All consecutive ACS patients presenting for PCI between January,2013 and December,2013 in Fuwai hospital were included.We evaluated 2-year major adverse cardiovascular and cerebrovascular events(MACCE,including all-cause death,cardiac death,myocardial infarction,revascularization and stroke)following PCI.The patients were divided into STEMI and NSTEACS according to ECG type,and patients with previous surgical history of coronary artery bypass grafting(CABG),primary PCI and CABG were excluded.Patients were followed for 2 years,and major cardio cerebrovascular adverse events(MACCE,including all-cause death,cardiac death,myocardial infarction,revascularization,and stroke)were recorded.Comparisons between baseline data were performed by student’s t-test and Pearson’s chi square test.Propensity score matching was used to adjust for imbalances in baseline data.And the Cox regression method was used to compare the independent risk factors of major cardio cerebrovascular adverse events.Subgroup analyses were performed according to age,gender,LVEF,eGFR,and presence or absence of three vessel disease.P<0.05 was considered statistically significant.Results:There were significant differences between STEMI(n=540)and NSTEACS(n=2314)in basic characteristics,coronary artery disease and intervention.2-year follow-up showed that compared with NSTEACS,STEMI patients had significantly higher risk of all-cause death(4.3%vs.1.6%,p<0.001),cardiac death(2.8%vs.0.8%,p<0.001)and MACCE(16.1%vs.12.5%,p=0.025).Multivariate Cox regression analysis showed that STEMI was independent risk factor of all-cause death(HR=2.68,95%CI:1.55-4.63,P<0.001)and cardiac death(HR=3.08,95%CI:1.52-6.25,P<0.001).After propensity score matching,there was no significant difference in MACCE events between the two groups.STEMI was no longer a predictor of MACCE events.The increasing of age and LVEF<40%were independent risk factors for all-cause death and cardiac death.Subgroup analysis showed that the risk of all-cause mortality was significantly higher in older female patients with STEMI than in male patients(p for interaction=0.023).However,in subgroup of older than 75 years,reduced cardiac function,three vessel disease and reduced renal function,the type of ACS did not affect the risk of all-cause mortality.Conclusions:(1)The 2-year risks of all-cause death,cardiac death,and MACCE were higher in patients with STEMI than in patients with NSTEACS;there was no significant difference between the 2 groups after propensity score matching.(2)STEMI was an independent risk factor for all-cause death,cardiac death,and MACCE.After propensity score matching,STEMI was no longer an independent risk factor for all-cause death,cardiac death,and MACCE.(3)The risk of all-cause mortality in elderly women with STEMI is significantly higher than that in men.(4)The increasing of age exacerbates the risk of mortality in elderly patients,but not related to the type of ACS.