Study Fails to Support Routine PCI for Older Patients With Syncope and CAD

Older patients hospitalized with syncope who are subsequently found to have obstructive CAD may benefit from either PCI or medical therapy, a study suggests. But while PCI may offer a slight mortality advantage over medication alone, it also may increase the risk of MI, leading researchers to urge caution when deciding between the two options. 

“This is probably one of the most data sparse areas in the whole arena of cardiology,” senior author Tracy Y. Wang, MD (Duke University Medical Center, Durham, NC), told TCTMD. Unfortunately, syncope is a common geriatric problem, she added, and the lack of data only compounds uncertainty about whether revascularization is the best option.   

“There is almost no data on whether PCI is beneficial for syncope patients,” Wang said. “A lot of times in these cases I think the clinicians are doing the cath just to get a sense of what the coronaries are and then they are stepping back and saying, given the uncertain benefit of PCI, do I really want to treat the lesion that I just found?”   

In an early-online paper from the March 14, 2016, issue of JACC: Cardiovascular Interventions, Wang and colleagues led by Lindsay L. Anderson, MD, retrospectively reviewed management decisions and outcomes among 14,674 syncope patients age 65 and older treated at 539 CathPCI Registry hospitals. Two-thirds of patients (9,549) were found to have both syncope and at least one vessel with obstructive CAD. After excluding patients with STEMI, cardiogenic shock, significant left main disease, and those who underwent CABG within a month of their initial hospitalization, 3,196 patients were sent for PCI and 4,142 were managed medically.    

Mortality Advantage for PCI Tempered by Increased MI Risk   

Propensity matching resulted in two groups of 2,503 patients each. When these groups were compared, there was no difference in risk of 90-day readmission for any cause, or in readmission for syncope at 3 years. PCI-treated patients had higher survival at 3 years but were more likely to have an MI, however.    

When analysis was confined to the subsets of higher-risk patients with syncope and ACS or with syncope and abnormal stress test results, the increase in MI remained for the PCI group but the long-term mortality advantage disappeared.  

Provider Uncertainty Evident

Anderson and colleagues say the fact that, even after a finding of an obstruction on catheterization, only 44% of patients underwent PCI is unsurprising in light of the limited evidence. This shows a reluctance to intervene invasively that “reflects provider uncertainty of benefit versus risk, and may be tempered by patient preference in the absence of definitive guideline recommendations,” they say.

Providers also may want to avoid the procedural and bleeding risks associated with long-term antithrombotic therapy in these older patients, they add. Furthermore, the lack of difference in readmission rates for syncope suggests that medical management is effective in this population.

“It was reassuring [that] the likelihood of them coming back for syncope-related problems was less than 10%,” Wang observed. “But as a group these are patients who use a lot of resources . . . so, I think there is room for improvement in how these patients can be managed over time to optimize their medical therapy and reduce the need for future caths.”

According to the researchers, the bottom line for clinicians is that syncope should not be attributed to CAD until a guideline-based systematic evaluation excludes other causes and there are reasons tosuspect an ischemic etiology related to CAD. Overall, they say, the results do not support routine PCI in this population to prevent future coronary events.

Wang suggests that when CAD is found in patients with syncope, “we need to be a little more cautious with whether or not to pull the trigger on revascularization. The key lesson we’ve learned with PCI over the years is PCI treats symptoms, it doesn’t necessarily reduce mortality.”

Source:  
Anderson LL, Dai D, Miller AL, et al. Percutaneous coronary intervention for older adults who present with syncope and coronary artery disease? Insights from the National Cardiovascular Data registry. Am Heart J. 2016;Epub ahead of print. 

Disclosures:

• Anderson and Wang report no relevant conflicts of interest. 

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