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Dr. Yim is Chief of Cardiothoracic Surgery and Drs. Arifi and Wan are cardiac surgeons in the Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.
Correspondence to: Anthony P.C. Yim, MD, FCCP, Chief, Division of Cardiothoracic, Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; e-mail: yimap{at}cuhk.edu.hk
Nowadays, people, especially women in industrialized societies, can aspire to a life expectancy such as the Biblical "three score years and ten" (70 years) and beyond. As a result of this lengthening in life expectancy, coronary artery bypass grafting (CABG) has become an increasingly common operation in the elderly population. Similar to previous reports from Europe and North America, in this issue of CHEST (see page 1262) Hirose and colleagues retrospectively compared CABG in young patients vs elderly patients (ie, people > 75 years of age) over an 8-year period from a single institution in Japan, a country with one of the longest life expectancies. The authors showed that the mortality and morbidity for CABG were both higher in the elderly group. However, they also observed that it was the coexisting morbidity (eg, cardiac or renal failure) rather than the advanced age per se that was responsible for early and late deaths. There was no difference in the cardiac event-free survival rates between the two groups.
These findings seem to be consistent with those in reports from Western societies, with the exception that in Japan the average postoperative hospital stay (18 days for the young and 21 days for the elderly) is much longer than in most medical centers in the United States. This reflects differences in the expectations of patients and, more so, in the health-care delivery systems (ie, the predominantly managed care in the United States vs a highly centralized, government-funded [taxpayer-supported] health-care program in Japan). A detailed discussion of the different health plans is beyond the scope of this editorial. Nevertheless, it is important to emphasize that the length of hospital stay is often not viewed by health-care administrators as an important index on the quality of health care outside the United States— at least not yet.
Although it has been clearly demonstrated in this and other published series that CABG in the geriatric population is associated with higher risk compared to the young population, surgery may still offer the best chance to these elderly patients. Nonsurgical revascularization, like percutaneous transluminal coronary angioplasty, has not been shown to be associated with a lower mortality rate compared to CABG. In fact, analysis of data from a randomized trial (the bypass angioplasty revascularization investigation)1 investigating bypass vs angioplasty revascularization showed that CABG should be the preferred strategy for revascularization in elderly patients > 65 years of age who have diabetes. The late outcome of these patients after surgery is often very gratifying, and a 1998 study showed that > 80% of them enjoyed a good quality of life.2
The surgical treatment of elderly patients nonetheless presents a special challenge that is related to the physiologic process of aging and to a decrease in the functional reserve of the organs. Patient selection for surgery is not always straightforward, but the majority of these patients are operated on for symptoms rather than for prognosis.3 It has been shown recently that advanced age remains an independent predictor of delayed extubation and a requirement for prolonged intensive care, despite advances in "fast-track" management.4 As far as the operative strategy is concerned, patients who are frail with numerous comorbidities may tolerate poorly procedures with a long duration of ischemia and pump-run. Hence, expediency is more important for elderly patients than for younger, fitter patients. On the other hand, recent reappraisal of off-pump CABG has shown great promise in reducing postoperative complications in the elderly compared to the conventional approach.5
Therefore, from the standpoint of patients, families, physicians, and society as a whole, it should be recognized that CABG in the elderly carries an increased risk, but, in the surgeon’s view, patients should not be turned down for surgical revascularization because of advanced age alone.
References
This article has been cited by other articles:
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  I. Shapira, A. Isakov, I. Heller, and M. Topilsky Elderly Patients as Candidates for Bypass? Chest, January 1, 2001; 119(1): 318 - 319. [Full Text] [PDF]
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