The fate of coronary artery bypass grafting in the elderly: treat and forget

Background: Coronary artery bypass grafting (CABG) is offered to a growing population of octogenarians, considering the constant rise of life expectancy. However, the mid-term benefit of surgical revascularization is still unclear. The aim of this study is to highlight the 10-year outcomes after isolated CABG in the elderly included in the Italian nationwide PRIORITY cohort. Methods: Patients younger and older than 80 years were identified within the PRIORITY project. Baseline differences between the study groups were balanced with propensity score matching and inverse probability of treatment. Time to events was analyzed using Cox regression and competing risk analysis. Results: The cohort consisted of 10 989 patients who underwent isolated CABG (7.9% OPCAB). The median follow-up time was 7.9 years. Octogenarians showed poorer 10-year survival [hazard ratio (HR) 3.09, 95% confidence interval (CI) 2.93-3.25, P < 0.001] and major adverse cardiac and cerebrovascular events (HR 2.13, 95% CI 2.04-2.22, P < 0.001). Interestingly, although presenting higher incidence of myocardial infarction (MI) at 10 years (HR 1.39, 95% CI 1.29-1.50, P < 0.001), octogenarians demonstrated a reduced incidence of 10-year myocardial revascularization (HR 0.53, 95% CI 0.48-0.59, P < 0.001), corroborating the hypothesis of undertreatment for elderly. Conclusions: With the increasing incidence of octogenarians undergoing CABG, undertreatment after surgery appears a critical issue. The higher incidence of 10-year MI, together with the opposite rate of myocardial revascularization, suggests a tendency for conservative approaches, opening a debate on the choice of treating the elderly with CABG without guaranteeing a clinical assistance comparable to younger patients.