Left main coronary artery disease in adults younger than 50 years: a comparison with older patients

Pharmacotherapy for Coronary Artery Disease and Acute Coronary Syndrome in the Aging Population

PURPOSE OF REVIEW

To provide a comprehensive summary of relevant studies and evidence concerning the utilization of different pharmacotherapeutic and revascularization strategies in managing coronary artery disease and acute coronary syndrome specifically in the older adult population.

RECENT FINDINGS

Approximately 30% to 40% of hospitalized patients with acute coronary syndrome are older adults, among whom the majority of cardiovascular-related deaths occur. When compared to younger patients, these individuals generally experience inferior clinical outcomes. Most clinical trials assessing the efficacy and safety of various therapeutics have primarily enrolled patients under the age of 75, in addition to excluding those with geriatric complexities. In this review, we emphasize the need for a personalized and comprehensive approach to pharmacotherapy for coronary heart disease and acute coronary syndrome in older adults, considering concomitant geriatric syndromes and age-related factors to optimize treatment outcomes while minimizing potential risks and complications. In the realm of clinical practice, cardiovascular and geriatric risks are closely intertwined, with both being significant factors in determining treatments aimed at reducing negative outcomes and attaining health conditions most valued by older adults.

Outcome of coronary artery bypass grafting in a tertiary-care center in Pakistan

BACKGROUND

Coronary artery bypass grafting and percutaneous coronary intervention are revascularization options for significant coronary artery disease. While international data support the use of coronary artery bypass in high-risk groups, regional data on outcomes in these groups are rare. We conducted a retrospective study to determine the outcomes of patients undergoing coronary artery bypass for left main and multivessel disease.

METHODS

Two thousand eight hundred and fifty-one patients undergoing coronary artery bypass at the Aga Khan University Hospital from 2006 to 2013 were included; patients undergoing redo surgery were excluded. Demographic data, comorbidities, angiography findings, in-hospital complications, one-month and one-year follow-up were analyzed.

RESULTS

Of the 2851 patients, 568 had left main disease (group 1) and 2283 (group 2) had multivessel disease (≥2 vessels excluding the left main). Group 1 had significantly more chronic lung disease, cardiogenic shock, and congestive heart failure than group 2 (p < 0.001); 50.6% of patients were diabetic and 71.8% were hypertensive. Mortality was 5.1% and 2.2% during hospital stay, 6.5% and 2.6% at 30 days, and 6.7% and 2.7% at 1 year in groups 1 and 2, respectively.

CONCLUSION

Our comparable results and international data advocate revision of the current practice of using percutaneous coronary intervention over coronary artery bypass in the developing world. Institutional results are essential to determine the outcome of coronary artery bypass in high-risk populations with a high burden of diabetes and hypertension. We noted increased complications and mortality in patients with left main rather than multivessel disease.

Prevalence of unfavorable angiographic characteristics for percutaneous intervention in patients with unprotected left main coronary artery disease

OBJECTIVES

The goal of this study was to determine the proportion of patients with left main coronary disease (LMCD) with unfavorable characteristics for percutaneous coronary intervention (PCI).

BACKGROUND

Published series suggest that LMCD can be treated percutaneously, however, the proportion of patients in whom PCI is an option based on angiographic criteria is unknown.

METHODS

In 13,228 consecutive coronary angiograms, 476 (3.6%) patients had < or =60% stenosis of the left main. In 232 patients with unprotected LMCD, the clinical characteristics and angiograms were reviewed with six features chosen as "unfavorable" for PCI: (1) Bifurcation LMCD, (2) occlusion of a major coronary, (3) ejection fraction <30%, (4) occlusion of a dominant RCA, (5) left dominant circulation, and (6) coexisting three-vessel disease. Treatment modality and 1 year mortality were determined.

RESULTS

The mean age was 69 years and 68% were male. Unfavorable characteristics were common with at least one unfavorable characteristic seen in 80%. Bifurcation disease was the most common unfavorable characteristic observed (53%) and coexisting three-vessel disease was seen in 38%. Treatment consisted of CABG in 205 (88%), medical therapy in 24 (10%) and PCI in 3 (1%). Among patients referred for CABG, 1 year survival was 88% with similar rates of survival for those with favorable characteristics (86%) compared to those with at least one unfavorable characteristic (88%).

CONCLUSIONS

Most patients with LMCD have at least one unfavorable characteristic for PCI suggesting that PCI may be a technically difficult option for most patients with LMCD.