Cardiovascular disease is the leading cause of death in men and women in this country. The vast majority is due to atherosclerotic vascular disease affecting the arteries which bring blood supply to the heart, to the brain and to other vital organs. The atherosclerotic process is a chronic degenerative one, which is prone to acute exacerbations, frequently with catastrophic consequences heart attack, stroke, and, all too often, death.
The elderly comprise the fastest growing segment of our population. Current estimates predict that the proportion of the population over the age of 75 is likely to double over the next quarter century, due in part to an enhanced life expectancy, and in part to the “baby boom” phenomenon. Nearly half of the people–our parents and grandparents–are afflicted with one form or another of cardiovascular disease. Unless the disease is recognized and aggressively treated with risk factor control, atherosclerosis tends to be progressive over time. Therefore, this process is usually quite advanced in the elderly by the time they come to medical attention. “How can it be that all the arteries bringing blood to my heart are blocked?? Until last week I felt fine!!” This is an all-to-common refrain following critical diagnostic cardiac catheterization.
Treatment for acute coronary artery disease has enjoyed remarkable progress over the past two decades. The discovery and development of percutaneous intravascular interventions angioplasty, atherectomy and stenting which can be performed without the rigors of large surgical incisions or general anesthesia, have revolutionized the treatment of cardiovascular disease. At the same time, surgical treatment of coronary artery disease has improved dramatically, with an ever-dropping mortality rate despite an increasingly more difficult and high risk patient population. In the ancient days of my surgical training, cardiac catheterization was rarely performed on a patient older than 70, because the only treatment that could be offered beyond medical therapy was coronary bypass surgery, which was felt to be too risky in such an elderly population. With the advent of angioplasty, diagnostic catheterization was performed on increasingly elderly patients, with the hope of finding a lesion which could be easily dilated with a catheter. All too frequently, what was discovered was a patient with severe three-vessel disease affecting all the arteries to the heart that could be treated only with surgery. And surgeons developed the skills to operate on this increasingly elderly and more fragile population with ever-improving results. Today, nearly half the patients receiving surgical coronary revascularization are over the age of 70, yet the mortality rate is substantially less than it was on a much younger population two decades ago.
Comparative studies have generally shown that patients with critical blockages to only one coronary artery, or even two, with a normal heart function, generally do better with percutaneous intervention. Those with more advanced or complex disease, or with reduced ventricular function, generally do better with surgery. So here comes the critical question. As patients aged past 80 years, the longevity of the benefit from any given intervention is significantly reduced (as compared with a patient with a similar anatomic situation who was age 60, for example). Even though octogenarians tend to have the more extensive and complex disease, the type that generally does better with surgery, do the long-term benefits of surgery warrant the risks involved in this elderly population?
The Florida Heart Research Institute has addressed this question directly and performed an exhaustive follow-up study of over 1000 patients age 80 and older who underwent coronary artery bypass surgery to determine if the long-term patient perception of the quality of life warranted the risk of the intervention. We determined that, over time, surgical skill has improved such that mortality rates have decreased to less than one half of what they were a decade ago. Nonetheless, surgical survivors were restored to a long-term life expectancy and perceived quality of life comparable to the general population of comparable age who do not have cardiovascular disease. Therefore, it would appear that we now have the ability to offer our elderly friends the same options for interventional therapy that is available to their children.
Post Views: 1,228
