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Ann Thorac Surg 1995;60:875-876
© 1995 The Society of Thoracic Surgeons
Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
The populations of the United States and other industrialized countries are aging, and the fastest growing population in the United States is the group more than 85 years of age. In the current era of health care reform, which is a euphemism for concern about costs, the ability to provide appropriate care for patients more than 80 years old at an acceptable cost is a major individual human as well as societal concern. As the most common major operation in the United States, at more than 300,000 performed annually [1], the use of coronary artery bypass grafting in the elderly is quite naturally a major issue. At present there are no randomized clinical trials that specifically address coronary operations in the elderly, and it seems unlikely that one can, should, or will be mounted. Thus, we are left with clinical series, as those found in this issue of The Annals.
The series by Cane and associates [2] and Williams and colleagues [3] add significantly to our understanding of coronary operations in patients more than 80 years of age. In the former series 121 patients (mean age, 82 years; 69% with isolated coronary bypass) underwent operation between 1982 and 1991. In-hospital mortality was 9.1%. Survival at 4.5 years was approximately 55%, which was identical to a sex-, race-, and age-matched control population. In the latter series, 300 patients (mean age, 81 years) underwent bypass grafting between 1989 and 1994. In-hospital mortality was 11%. Survival at 4.5 years was approximately 75% for hospital survivors. Thus, counting hospital and late deaths, error, and censoring of patients with incomplete follow-up, the two series cannot be said to differ in results. Given these two series and several other reports in the literature [4–8], survival after coronary operations in octogenarians will be in the range of 50% to 70% by 4 to 5 years and will be similar to the general population. Also consistent with prior studies [4, 6], these studies showed good relief of disabling angina.
Can these studies tell us who should have a coronary operation? Here these studies, as is true of the previous literature, are only of limited help. In the study by Williams and colleagues, the correlates of hospital mortality were determined, and in the study by Cane and associates correlates of both hospital and late mortality were determined. In neither study were the details of the models presented in such a way that the clinician could develop an adequate assessment of risk by severity of disease or co-morbid factors. There is a more fundamental problem in that the series are small and the number of events limited. With multiple possible independent variables, there will be serious overmodeling in small series, and there may be important variables that do not appear significant as well as uncertainty about the importance of the variables that appear significant. The appropriate way of looking at outcome modeling in a small series is to read it with interest, but realize that it cannot be considered definitive. Furthermore, there may be important variables, such as frailty, that are hard to measure but may be very important. Other variables may be easy to measure, but the distributions may mask their importance. The obvious example of this is age, as the patients clustered toward the lower end of the age range. Thus, even though it was not apparent in these data, the mortality for patients in their late 80s to early 90s may be considerably higher both initially and long term than for patients in their early 80s. From a somewhat more clinical stance we can expect lowest risk in the elderly who are robust, do not have serious co-morbidity, do not have severe left ventricular dysfunction, and who can be well revascularized. Conversely, the oldest of the old who are frail, have serious co-morbidity, and more severe heart disease should be at increased risk. Larger series may bear this out.
Improved myocardial preservation, anesthesia, surgical technique, and perioperative care have improved the results of operations over the last several years. This is probably also true of the elderly, and so we can operate on many patients older than 80 years reasonably safely. Most patients are feeling better several years after their operation. However, just which patient should we operate on? Even if the healthiest have the lowest risk, there may be benefit, maybe even more benefit, in those who are sicker. These series as well as others suggest that patients more than 80 years of age are not referred to operation as frequently as younger patients [9]. After all, coronary disease is very common in the elderly, but patients older than 80 years are a small fraction of virtually all series. This suggests that clinicians are conservative about referral of patients older than 80 years.
Then what are the indications? Simply put, coronary operation in patients older than 80 years is indicated for severe angina poorly controlled by medication or to prolong life. For severe disabling angina, perhaps in patients with disease not amenable to angioplasty, and in patients at a reasonable level of risk, the decision to proceed with a coronary operation is straightforward. To perform coronary bypass grafting in patients older than 80 years to prolong life may seem unlikely, and certainly cannot be supported by the literature. Although the data presented in the two studies in this issue of The Annals may appear to restore patients to a level of survival consistent with an age-matched population, survival benefit still cannot be assumed as patients older than 80 years who are fit enough for a coronary operation may be otherwise healthier than a matched population. Nonetheless, in patients with life-threatening ischemia not amenable to revascularization in any other way, the decision to proceed with operation will at times be warranted to prolong life. Finally, we may consider left main coronary disease or three-vessel disease with mild symptoms. These are the patient groups in which there are the best data in younger patients that a coronary operation can prolong life. However, it is an assumption that one can extend the applications of these data to patients older than 80 years. There can be no absolute answer for these otherwise usual surgical candidates.
Finally, how is society to react to coronary operations in a geriatric population when medical care is under such budgetary pressure? Here are some points to consider: First, this is not an enormous problem, at least at present, because coronary operations in octogenarians remain a small percentage of cases. As noted above, cardiologists and surgeons are already selective in referring patients. Second, the issues of case selection are difficult for the reasons discussed. Third, as the series presented in this issue demonstrate, with proper selection, most patients do well. Thus, from the standpoint of patients, families, physicians, payers, and society as a whole, care must be taken in deciding to send an octogenarian to a bypass operation, but the operation should not be denied to a patient on the basis of age alone.
Footnotes
Address reprint requests to Dr Weintraub, Division of Cardiology, Emory University Hospital, 1365 Clifton Rd NE, Atlanta, GA 30322.
References
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  K. B. Ramanathan, D. S. Weiman, J. Sacks, D. A. Morrison, S. Sedlis, G. Sethi, and W. G. Henderson Percutaneous Intervention Versus Coronary Bypass Surgery for Patients Older Than 70 Years of Age With High-Risk Unstable Angina Ann. Thorac. Surg., October 1, 2005; 80(4): 1340 - 1346. [Abstract] [Full Text] [PDF]
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 A. P. C. Yim, A. A Arifi, and S. Wan Coronary Artery Bypass Grafting in the Elderly : The Challenge and the Opportunity Chest, May 1, 2000; 117(5): 1220 - 1221. [Full Text] [PDF]
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