Therapie der koronaren Dreigefäßerkrankung bei Patienten über 75 Jahren

Zusammenfassung

Hintergrund und Fragestellung | Chronisch-ischämische Herzerkrankungen sind Todesursache Nr. 1 in Deutschland. Der Anteil der ≥ 75-Jährigen beträgt dabei über 80 %. Älteren Patienten kommt aufgrund ihres zunehmenden Bevölkerungsanteils in der medizinischen Versorgung eine immer größere Bedeutung zu. In dieser Arbeit charakterisieren wir Patienten ≥ 75 Jahre mit koronarer Dreigefäßerkrankung und vergleichen verschiedene Therapiestrategien miteinander.

Patienten und Methodik | Retrospektiv wurden die Daten der ≥ 75-jährigen Patienten gesammelt, bei denen in den Jahren 2005 bis 2007 im Klinikum Lippe Detmold mittels Koronarangiografie eine koronare Dreigefäßerkrankung festgestellt wurde. Je nach erhaltener Therapie erfolgte eine Einteilung in eine der folgenden drei Gruppen:

• optimale medikamentöse Therapie (OMT)

• perkutane Koronarintervention (PCI)

• operative Revaskularisierung mit Koronararterien-Bypass (CABG)

Wir ermittelten die Patientencharakteristika sowie die Raten von Überleben und schweren kardialen und zerebrovaskulären Komplikationen (MACCE) im Nachbeobachtungszeitraum. Es wurden Subgruppenanalysen durchgeführt für das akute Koronarsyndrom (ACS) und die stabile koronare Herzkrankheit (KHK).

Ergebnisse | Dokumentiert wurden die Daten von 434 Patienten mit einem durchschnittlichen Alter von 79 Jahren.

• 139 Patienten (32,0 %) erhielten eine OMT,

• 189 Patienten (43,6 %) eine PCI und

• 106 Patienten (24,4 %) wurden mit CABG behandelt.

Im Gesamtkollektiv gab es keinen signifikanten Unterschied bezogen auf die Mortalität zwischen den drei Therapiegruppen. In der Subgruppe der Patienten mit einem akuten Koronarsyndrom (n = 180) zeigte sich eine signifikant erhöhte Mortalität in der OMT-Gruppe im Vergleich zu den beiden invasiven Therapien (PCI: p = 0,029, CABG: p = 0,045). In der Subgruppe der Patienten mit stabiler KHK (n = 254) zeigten sich keine signifikanten Mortalitätsunterschiede zwischen den drei Therapieformen.

Folgerungen | Patienten mit akutem Koronarsyndrom profitieren auch im hohen Alter von einer interventionellen oder operativen Revaskularisierung. Im Gegensatz dazu stellt bei alten Menschen mit stabiler KHK eine optimale medikamentöse Therapie eine begründete Alternative zur invasiven Therapie ohne Mortalitätsanstieg dar.

Abstract

Background: Chronic ischemic heart disease take the first place in cause of death in Germany. The proportion of patients aged 75 years or older amounts more than 80 %. Due to their growing part of population the medical care of older patients becomes increasingly important. In this investigation patients aged ≥ 75 years with coronary three-vessel disease were characterized and various treatment strategies were compared.

Patients and methods: This analysis was retrospective. The data of patients aged 75 years or older with three-vessel disease diagnosed by coronary angiography at the Klinikum Lippe Detmold between 2005 and 2007 were collected. Depending on the received therapy they were parted in three groups: optimal drug therapy (OMT), interventional – (PCI) and surgical revascularization (CABG). Patient characteristics as well as survival- and MACCE-rates during follow up were ascertained. Subgroup analyzes were performed for acute coronary syndrom (ACS) and stable coronary artery disease( CAD).

Results: The data of 434 patients with an average age of 79 years were documented. 139 (32.0 %) were assigned to the OMT- 189 (43.6 %) to the PCI- and 106 (24.4 %) to the CABG-group. Overall there was no significant difference between the three groups regarding mortality. In the subgroup of patients wit ACS (n = 180) mortality significantly increased in the OMT-group compared to the two invasive therapies (PCI (p = 0.029), CABG (p = 0.045)). The subgroup of patients with stable CAD showed no significant differences in mortality between the three types of therapy.

Conclusions: Older patients benefit from an interventional or surgical revascularization in the context of ACS. In contrast, in elderly with stable CAD optimal medical therapy provides a reasonable alternative to invasive therapy without increase in mortality.

Schlüsselwörter

Dreigefäßerkrankung - Alter - koronar - PCI - CABG

Keywords

three-vessel disease - age - coronary - PCI - CABG

• Literatur

• 1 Statistisches Bundesamt. Todesursachen in Deutschland 2013. Fachserie 12 Reihe 4 https://www.destatis.de/DE/Publikationen/Thematisch/Gesundheit/Todesursachen/Todesursachen2120400137004.pdf?__blob=publicationFile. Letzter Zugriff am 01.02.2016
• 2 Lee PY, Alexander KP, Hammill BG et al. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA 2001; 286: 708-713
• 3 Golomb BA, Chan VT, Evans MA et al. The older the better: are elderly study participants more non-representative? A cross-sectional analysis of clinical trial and observational study samples. BMJ Open 2012; 2: e000833
• 4 Pfisterer M, Buser P, Osswald S et al. Outcome of elderly patients with chronic symptomatic coronary artery disease with an invasive vs optimized medical treatment strategy: one-year results of the randomized TIME trial. JAMA 2003; 289: 1117-1123
• 5 Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003; 361: 13-20
• 6 Jeremias A, Kaul S, Rosengart TK et al. The impact of revascularization on mortality in patients with nonacute coronary artery disease. Am J Med 2009; 122: 152-161
• 7 Schomig A, Mehilli J, de Waha A et al. A meta-analysis of 17 randomized trials of a percutaneous coronary intervention-based strategy in patients with stable coronary artery disease. J Am Coll Cardiol 2008; 52: 894-904
• 8 Yusuf S, Zucker D, Peduzzi P et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994; 344: 563-570
• 9 Pfisterer M. Trial of Invasive versus Medical therapy in Elderly patients I. Long-term outcome in elderly patients with chronic angina managed invasively versus by optimized medical therapy: four-year follow-up of the randomized Trial of Invasive versus Medical therapy in Elderly patients (TIME). Circulation 2004; 110: 1213-1218
• 10 TIME Investigators. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial. Lancet 2001; 358: 951-957
• 11 Aziz O, Rao C, Panesar SS et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007; 334: 617
• 12 Kapoor JR, Gienger AL, Ardehali R et al. Isolated disease of the proximal left anterior descending artery comparing the effectiveness of percutaneous coronary interventions and coronary artery bypass surgery. JACC Cardiovasc Interv 2008; 1: 483-491
• 13 Mohr FW, Morice MC, Kappetein AP et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013; 381: 629-638
• 14 Bavry AA, Kumbhani DJ, Rassi AN et al. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006; 48: 1319-1325
• 15 Fox KA, Clayton TC, Damman P et al. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol 2010; 55: 2435-2445
• 16 Serruys PW, Morice MC, Kappetein AP et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360: 961-972
• 17 Hueb W, Lopes N, Gersh BJ et al. Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation 2010; 122: 949-957
• 18 Kelly DJ, McCann GP, Blackman D et al. Complete Versus culprit-Lesion only PRimary PCI Trial (CVLPRIT): a multicentre trial testing management strategies when multivessel disease is detected at the time of primary PCI: rationale and design. EuroIntervention 2013; 8: 1190-1198