April 29, 2022

Kaiser Permanente Northern California study found long-term benefit for medical outcomes and quality of life

Older adults who experience a heart attack — and their family members — might assume it’s better and safer to insert a stent via an artery in the groin or wrist to open the narrowed arteries that blocked the flow of blood to the heart than opt for a more difficult open-heart bypass surgery. But a new Kaiser Permanente study suggests that for many seniors, bypass surgery may lead to better long-term outcomes.

Ahmed Ijaz Shah, MD

Ahmed Ijaz Shah, MD, interventional cardiologist, The Permanente Medical Group.

“Initially we thought inserting the stent might be better because the recovery is so much shorter, and you get out of the hospital much more quickly,” said lead author Ahmed Ijaz Shah, MD, an interventional cardiologist with The Permanente Medical Group and medical director of the Oakland cardiac catheterization laboratory.

“We know that in younger patients bypass surgery is a better option for multi-vessel or left main coronary artery disease compared to stenting,” said Dr. Shah. “But we were surprised to see that bypass surgery was associated not only with increased quantity of life, but also an improved quality of life for older people. This improvement in quality was seen after the first year and continued over time.”

The study, published in the Journal of the American Geriatrics Society, included 3,871 members of Kaiser Permanente Northern California age 65 and older who were diagnosed between 2010 and 2018 with an acute coronary syndrome (heart attack) caused by fatty deposits (plaque) that had created a blockage in the left main artery or in multiple arteries in the heart.

The research team reviewed the patients’ medical records to see which patients were treated with a coronary artery bypass and which received a stent. They then looked at the patients’ medical outcomes, such as death from any cause, second heart attack, need to start dialysis, stroke, or rehospitalization. They also assessed the number of days alive out of the hospital (DAOH) each patient had after their stent placement or bypass surgery. DAOH, or time spent at home and not in a hospital, skilled nursing facility, or long-term rehabilitation center, is a relatively new, patient-centered approach for assessing quality of life in research studies on older adults.

The study found no statistically significant difference between the 2 groups of patients at 1 year post-treatment in DAOH, with patients in both groups doing equally well. But over time, that changed. At 5 years post-treatment, the patients who had bypass surgery had better quality of life — having spent, on average, 131 fewer days in the hospital — than the patients who had had a stent inserted.

Ashok Krishnaswami, MD, MAS

Ashok Krishnaswami, MD, MAS, cardiologist, The Permanente Medical Group; DARE clinician-researcher.

“You have to be careful how you interpret the findings, because this is observational, population-based research,” said senior author Ashok Krishnaswami, MD, MAS, a cardiologist with The Permanente Medical Group and a clinician-researcher with the Delivery Science and Applied Research (DARE) cardiology research group.

“It’s always possible it was the healthier patients who had the bypass surgery,” said Dr. Krishnaswami. “But we used analytic techniques that could help us take that into account, as well as other differences. We believe these findings are a step toward the development of future clinical trials that will focus on these older patients with complex geriatric conditions, who must make these choices.”

People 65 and older are more likely to have a heart attack or to develop heart disease than younger people. And with people living longer, it’s becoming more common to see people in their 70s and 80s with multiple health problems having to choose between a stent and a heart bypass surgery. This confluence has given rise to field known as geriatric cardiology.

Dr. Krishnaswami, who leads the geriatric cardiology program at Kaiser Permanente Northern California, said this study will be a key contribution to this growing field. “To take care of older adults, you don’t need to be a geriatrician,” he said. “But you do need to have additional training in geriatrics to understand their competing health needs. This study was a collaboration between an amazing group of clinician researchers and statisticians at the Kaiser Permanente Northern California Division of Research who could help us not only to get the data but to do these specific analyses.”

Added Dr. Shah, “The take-home message for me from this study is that physicians shouldn’t rule out bypass surgery in older patients. Yes, it is a more invasive surgery. But with a multidisciplinary team of specialists, it should be considered. It can possibly lead to a better quality of life, and that is a primary concern of our older patients.”

This study was supported by Kaiser Permanente Northern California Community Health.

Co-authors include Amy Alabaster, MPH, and Makdine Dontsi, MS, of the Division of Research; and Jamal S. Rana, MD, PhD, and Matthew D. Solomon, MD, PhD, of the Division of Research and The Permanente Medical Group.