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Vol. 69. Issue 7.
Pages 711-712 (July 2016)
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Vol. 69. Issue 7.
Pages 711-712 (July 2016)
Letter to the Editor
DOI: 10.1016/j.rec.2016.03.012
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Octogenarians: Too Old for Surgical Myocardial Revascularization?
Octogenarios: ¿demasiado ancianos para revascularización miocárdica quirúrgica?
Diego Fernández-Rodrígueza,
Corresponding author
, José J. Grilloa, José L. Martos-Mainea, Francisco Bosa-Ojedab
a Servicio de Cardiología, Hospital Universitario Nuestra Señora de Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
b Servicio de Cardiología, Hospital Universitario de Canarias, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
Related content
Rev Esp Cardiol. 2016;69:217-910.1016/j.rec.2015.09.019
Felipe Díez-Delhoyo, Fernando Sarnago Cebada, Luis Manuel Cressa, Allan Rivera-Juárez, Jaime Elízaga, Francisco Fernández-Avilés
Rev Esp Cardiol. 2016;69:71210.1016/j.rec.2016.04.014
Fernando Sarnago Cebada, Felipe Díez-del Hoyo, Allan Rivera-Juárez, Francisco Fernández-Avilés
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To the Editor,

We would like to congratulate Díez-Delhoyo et al1 for their work on the prognostic value of the residual SYNTAX score (rSS) in octogenarians with non--ST-elevation acute coronary syndrome, and we would like to offer some comments.

Although the study was a retrospective analysis, the findings showed rSS to be a strong prognostic predictor in these patients. The study involved patients with multivessel disease, and the preferred treatment strategy was percutaneous revascularization of the culprit lesion. The primary endpoint (combined all-cause mortality and myocardial infarction) was compared against the rSS (rSS < 8, rSS 8-20 and rSS > 20) on admission and at 6 months. For both the admission period and the 6-month period, the primary endpoint increased significantly as the rSS increased. The main finding of the study was that in the multivariable analysis, rSS was found to be the greatest predictor of the primary endpoint at 6 months (odds ratio = 9.4; 95% confidence interval, 1.61-55.1; P = .013).

The selection of revascularization strategy in octogenarians is complex, due to the patients’ frailty and comorbidities and the extent of coronary disease. Therefore, percutaneous revascularization of the culprit lesion with medical management of the remaining lesions is a widely-practiced option. However, this strategy has some drawbacks:

  • Identification of the “culprit lesion”: in many patients with multivessel disease, a culprit lesion cannot be identified. Several studies have shown that up to 40% of patients have multiple plaques with angiographic criteria of a culprit lesion and that there is a weak correlation between the culprit lesion and the electrocardiographic and echocardiographic changes.2

  • The natural history of “nonculpable lesions”: in stable coronary disease, coronary lesions can remain quiescent for long periods. However, after an acute coronary syndrome, nonculpable lesions can be “activated”, leading to short-term and long-term thrombotic events.3

  • Complete revascularization: complete revascularization is associated with lower morbidity and mortality and is easier to perform via surgical revascularization than via percutaneous revascularization.4 An rSS > 8 after incomplete percutaneous revascularization is associated with a poor prognosis,5 and the study by Díez-Delhoyo et al1 shows the usefulness of this score for octogenarian patients.

  • Surgical vs percutaneous revascularization: several studies comparing both types of revascularization in multivessel disease included patients with non--ST-elevation acute coronary syndrome and octogenarian patients, although there are no studies on this combination of factors specifically. For more than 20 years, numerous studies have compared surgical revascularization and percutaneous revascularization (angioplasty alone, conventional stents, and first- and second-generation drug-eluting stents). In general, surgical revascularization outcomes have been favorable,4,6 particularly in patients with intermediate to high complexity for percutaneous revascularization (baseline SYNTAX score > 22), as would be the case for octogenarians.

  • Surgical revascularization in octogenarians: although the inclusion of octogenarian patients in clinical trials has been limited,6 recent evidence from various real-world registries also indicates surgical revascularization to be the preferred alternative to percutaneous revascularization for such patients.7,8

In conclusion, according to the available evidence, surgical revascularization is a valid therapeutic option for octogenarians with non--ST-elevation acute coronary syndrome and multivessel disease. Therefore, in the absence of specific contraindications, the advanced age of octogenarian patients should not pose an obstacle to them benefiting from surgical revascularization.

F. Díez-Delhoyo, F. Sarnago Cebada, L.M. Cressa, A. Rivera-Juárez, J. Elízaga, F. Fernández-Avilés.
Valor pronóstico de la puntuación SYNTAX residual en pacientes octogenarios con síndrome coronario agudo sin elevación del segmento ST.
Rev Esp Cardiol., 69 (2016), pp. 217-219
J. Barrabes.
Comentarios a la guía ESC 2015 sobre el tratamiento de los síndromes coronarios agudos en pacientes sin elevación persistente del segmento ST.
Rev Esp Cardiol., 68 (2015), pp. 1061-1067
G.W. Stone, A. Maehara, A.J. Lansky, B. de Bruyne, E. Cristea, G.S. Mintz, et al.
A prospective natural-history study of coronary atherosclerosis.
N Engl J Med., 364 (2011), pp. 226-235
S. Garcia, Y. Sandoval, H. Roukoz, S. Adabag, M. Canoniero, D. Yannopoulos, et al.
Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies.
J Am Coll Cardiol., 62 (2013), pp. 1421-1431
P. Genereux, T. Palmerini, A. Caixeta, G. Rosner, P. Green, O. Dressler, et al.
Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: the residual SYNTAX (SYNergy between PCI with TAXus and cardiac surgery) score.
J Am Coll Cardiol., 59 (2012), pp. 2165-2174
S. Windecker, P. Kolh, F. Alfonso, J.P. Collet, J. Cremer, V. Falk, et al.
2014 ESC/EACTS guidelines on myocardial revascularization.
Eurointervention., 10 (2015), pp. 1024-1094
F. Nicolini, G.A. Contini, D. Fortuna, D. Pacini, D. Gabbieri, L. Vignali, et al.
Coronary artery surgery versus percutaneous coronary intervention in octogenarians: long-term results.
Ann Thorac Surg., 99 (2015), pp. 567-574
U. Benedetto, M. Amrani, T. Bahrami, J. Gaer, F. de Robertis, R.D. Smith, et al.
Survival probability loss from percutaneous coronary intervention compared with coronary artery bypassgrafting across age groups.
J Thorac Cardiovasc Surg., 149 (2015), pp. 479-484
Copyright © 2016. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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