Revascularisation for acute coronary syndromes in older people

BACKGROUND randomised controlled trials have demonstrated that early revascularisation improves outcome in patients with acute coronary syndromes. However, since older people were excluded from these trials, it is not known whether the findings are applicable to them. OBJECTIVES to evaluate the outcome of revascularisation by percutaneous coronary intervention or coronary artery bypass surgery in older people with acute coronary syndromes. To determine the factors which predict outcome of revascularisation in these patients. DESIGN systematic review of studies obtained from the Medline and Embase electronic databases and through bibliographic searches. Analysis by descriptive overview and statistical meta-analysis using pooled proportions. INCLUDED STUDIES studies published from 1990 onwards describing the outcome of percutaneous coronary intervention or coronary artery bypass surgery in patients 75 or 80 years, of whom 75% or more were classified as unstable angina. Studies published from 1990 onwards describing the factors predicting outcome of percutaneous coronary intervention or coronary artery bypass surgery in all patients 75 or 80 years. RESULTS 26 studies were included. In-hospital mortality from percutaneous coronary intervention was 5.4% (95% confidence interval 3.9% to 7.0%) and after coronary artery bypass surgery was 12.1% (9.5% to 14.7%). Large observational studies indicate expected 30-day mortality of 6-12% with medical treatment. Serious complications following percutaneous coronary intervention were rare, but there was a high rate of major adverse cardiac events over the following year. Major complications, including stroke, were common after coronary artery bypass. However, long-term survival and functional outcome in those who survived the peri-operative period were excellent. Clinical variables predicted those at highest risk from both percutaneous coronary intervention and coronary artery bypass. CONCLUSIONS percutaneous coronary intervention offers an attractive option for the management of older people with acute coronary syndromes and may improve outcome over conservative treatment. In contrast, coronary artery bypass carries a substantial mortality and morbidity, and is likely to be reserved for patients with refractory symptoms unsuitable for percutaneous intervention. Further data from randomised controlled trials are required.