JACC: Best care for the frail, elderly with CAD is still puzzling

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Patients treated solely with medications after suffering from chest pain, MI or coronary artery disease are more likely to die during the first year following their initial hospitalization, according to a study in the August issue of the Journal of the American College of Cardiology: Cardiovascular Intervention.

“Patients managed medically without stenting or bypass surgery tend to be elderly and frail, and in some sense we feel they have been overlooked," said senior author Matthew Roe, MD, cardiologist at Duke University Medical Center in Durham, N.C. “We wanted to find out what clinical factors were funneling them into a medicine-only group and what happened to them, when compared to patients who received stents and bypass procedures.”

Roe led a team of researchers in examining a subset of 8,225 patients from the SYNERGY trial, which compared the effects of two different anti-clotting drugs in heart patients.

Researchers included only patients who had undergone cardiac catheterization and who had been found to have at least one significant blockage in a coronary artery. A majority of the patients (52 percent) underwent coronary stent implantation to open their arteries, while 32 percent were medically managed, and 16 percent underwent coronary bypass surgery, according to the authors.

Investigators said the study revealed that patients in the medical management group were more likely to be elderly women with low body weight, and more likely to have had peripheral artery disease, high blood pressure, diabetes or a history of stroke or a previous bypass surgery.

Researchers found that with all else being equal, the risk of death was highest for the medically managed group and lowest for patients who underwent stenting. Death rates among medically managed patients increased rapidly during the first three months following release from the hospital, and stayed higher than those in the other two groups.

At one year, the mortality rate among the medically managed group was 7.7 percent, 3.6 percent for patients who underwent stenting and 6.2 percent among those who underwent bypass procedures.

“There are often very good reasons why stenting or bypass are not viable options for some patients. What this study tells us is that for these patients, who are medically managed, we need to come up with better treatment approaches that lessen their risk of death,” Roe said.