Percutaneous Coronary Intervention or Medical Therapy for Chronic Total Occlusion in Older Adults
Background: Managing coronary chronic total occlusion (CTO) in older adults remains challenging due to a scarcity of evidence. Objectives: We aimed to assess the association of attempted/successful CTO percutaneous coronary intervention (CTO-PCI) with quality of life (QoL) measures, all-cause mortality, and cardiovascular outcomes in studies that adequately represented older adults. Methods: A systematic search of 6 databases was performed to identify randomized trials and observational studies comparing CTO-PCI with optimal medical therapy (OMT) in adults, with particular inclusion of studies adequately representing older individuals. Meta-regression analyses were conducted to estimate relative risks (RRs) for key outcomes. Results: A total 29 studies encompassing 19,282 patients were included, of which 28 were observational. Compared with OMT, attempted CTO-PCI was significantly associated with reductions in cardiac death (RR: 0.55; 95% CI: 0.40-0.76), all-cause mortality (RR: 0.61; 95% CI: 0.50-0.75), and major adverse cardiovascular events (RR: 0.68; 95% CI: 0.60-0.78). Rates of myocardial infarction and revascularization were similar between groups. In analyses comparing successful vs failed CTO-PCI, only cardiac death and all-cause mortality were reduced. In addition, among the 4 studies that evaluated QoL, attempted/successful CTO-PCI yielded greater improvements than OMT/failed PCI. Evidence for the above results were derived from observational studies and remained less certain. Conclusions: In older adults, attempted or successful CTO-PCI may be associated with improved QoL and favorable cardiovascular outcomes compared with OMT; however, as these findings are largely derived from observational studies, they should be viewed as hypothesis-generating. Randomized trials in representative older populations are needed to confirm these associations.
