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• Posted August 28, 2023

Opening All Arteries Best When Heart Attack Strikes in Old Age: Study

After a heart attack, elderly adults have better odds for improved health and survival if all major heart vessels are cleared, not just the one that caused the heart attack.

Because these patients often have other medical conditions and may be frail, doctors frequently opt to open only the "culprit" blood vessel and leave other partially blocked vessels alone.

But new research on more than 1,400 patients aged 75 and older found that clearing all these vessels lowers the one-year risk for death, having another heart attack or stroke, or needing another procedure.

"This could be a real change in the practice because the actual standard of care in most older patients is just to treat the culprit lesion, because physicians are worried about complications. Basically, the idea was that the prognosis was worse if we do more," said lead researcher Dr. Simone Biscaglia, an interventional cardiologist at Ferrara University Hospital in Italy.

"What we found in the study is the exact opposite," Biscaglia said. "Complete revascularization should be pursued in older patients with heart attack and multi-vessel disease."

Other experts agree that treating all the arteries that are significantly blocked should become the standard of care regardless of a patient's age.

"Recent clinical trials have established that in patients with a heart attack complete revascularization by treating all significant coronary blockage is superior to just focusing on treating the culprit artery," said Dr. Gregg Fonarow, director of the Ahmanson-UCLA Cardiomyopathy Center in Los Angeles. Most of these trials have focused on younger patients, he said.

The findings in this trial "are impressive and suggest the complete revascularization strategy in heart attack is superior to a culprit lesion-only approach in patients age 75 or older," Fonarow said. "Together with prior studies, this approach is further established as the standard of care."

For the study, Biscaglia and his colleagues randomly assigned 1,445 men and women, half of them older than 80, to have only the culprit heart artery unblocked or all the major blocked arteries opened.

Among patients who had all their narrowed heart arteries opened, 9% died or had another heart attack within a year, compared with 14% of patients who only had one artery opened — a 36% reduction in risk, the researchers found.

For all the outcomes assessed together — death, another heart attack or stroke, or needing another procedure — 16% in the complete revascularization group had one of these outcomes, compared with 21% of those who had only one artery unblocked. That was a 27% reduction in risk.

Moreover, the procedure was equally safe in both groups of patients, the researchers noted.

"This study adds more credibility to a practice that has already been used in younger patients," said Dr. Gaurav Rao, an interventional cardiologist at Northwell Atlas Bass Heart Hospital in Manhasset, N.Y. "So this does change practice in dealing with patients who are over 75 years of age."

After a heart attack, these older patients "are going to benefit from complete revascularization rather than fixing only the culprit vessel and they are going to do better in the long run," he added.

The report was published online Aug. 26 in the New England Journal of Medicine and presented simultaneously at the European Society of Cardiology meeting in Amsterdam.

More information

The American Heart Association has more on heart attack.

SOURCES: Simone Biscaglia, MD, interventional cardiologist, Ferrara University Hospital, Italy; Gaurav Rao, MD, interventional cardiologist, Northwell Atlas Bass Heart Hospital, Manhasset, N.Y.; Gregg Fonarow, MD, director, Ahmanson-UCLA Cardiomyopathy Center, Los Angeles; New England Journal of Medicine, Aug. 26, 2023, online