Angioplasty Versus Coronary Artery Bypass in Octogenarians

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1 Angioplasty Versus Coronary Artery Bypass in Octogenarians Tej K. Kaul, FRCS, Barry L. Fields, MD, David A. Wyatt, MD, Christopher R. Jones, MD, and Donald R. Kahn, MD Department of Cardiac Surgery, Princeton-Baptist Medical Center, Birmingham, Alabama We retrospectively analyzed early and late results for two treatment strategies of significant coronary artery disease in 3 octogenarians seen in the last years. One hundred five patients or more years of age had percutaneous transluminal coronary angioplasty () and 5 had coronary artery bypass grafting (). The group differed from the group in having a greater proportion of women (71.4% versus 45.8%; p < 0.001); fewer patients with unstable angina (24.7% versus 33.6%; p < 0.04), acute myocardial infarction (11% versus 23%; p < 0.04), three-vessel coronary artery disease (% versus 56%; p < ), and a left ventricular ejection fraction less than or equal to 0. (% versus 21%; p < 0.008); and fewer vessels revascularized (1.2 ± 0.6 versus 3.5 ± 0.9; P < ). Hospital mortality was 8.57% after (9/14 failed ) and 5.8% after (4/14 emergent, 611 urgent, and 2/ elective). Hospital stay was 7 ± 0.9 days after and 14 ± 1.5 days after (p < 0.01). Independent predictors of hospital mortality obtained by multivariate analysis included failed and acute myocardial infarction ( group), a left ventricular ejection fraction equal to or less than 0., and acute myocardial infarction and emergency ( group). Survivors after both and showed a significant improvement in their New York Heart Association class. Actuarial survival at 5 years after was 55% and after it was 66% ip < 0.01). Cardiac event-free survival (deaths, myocardial infarction,, ) at 3 years was 61% after and 81% after (p < 0.01). In octogenarians, had a greater mortality and failure rate than in our younger patients. Overall morbidity was higher after than after (p < 0.05), given the nature and the severity of the increased risk factors in the group. (Ann Thome Surg ) A ccording to recent statistics [l], 3% of the US population in 19 is years of age or older. As the life expectancy of an average American is likely to improve beyond 75 years during this decade [2], we should expect a corresponding increase in the octogenarian population. It is obvious that this sector of the population is predisposed to the development of multisystem disorders, diminished vital organ function reserve, and some deterioration of physical and mental capacities. It is estimated that almost 18% of the octogenarians in the United States have significant coronary artery disease (CAD) [3], which remains a principal cause of their death [4]. Generally, there has been a reluctance on the part of the physicians, patients, and their relatives to rely on more aggressive interventions for their ischemic heart disease since these patients are believed to be a fragile populace. It appears that the decision to perform invasive procedures, eg angioplasty () or coronary artery bypass operation (), generally is guided by the severity and complexity of the disease and often is made too late [41, which contributes to a higher mortality and morbidity for these procedures in this age group [4, 5]. However, recent reports clearly indicate improved survival and benefits after and an accept- Accepted for publication April 11, Address reprint requests to Dr Kaul, Department of Cardiac Surgery, Princeton-Baptist Medical Center, 817 Princeton Ave, SW Suite 0, Birmingham, AL by The Society of Thoracic Surgeons able success rate after angioplasty in selected patients as compared with continued conventional medical therapy [4-6]. In this retrospective series we have analyzed results and benefits of the two therapeutic strategies ( and ) as used in octogenarians at our institution during the last years. Material and Methods Patients and Procedures We analyzed records of all octogenarians who received treatment for significant coronary artery disease confirmed by coronary angiogram between July 1982 and July 1993 at our hospital. The two treatment strategies used were primarily guided by coronary artery anatomy and the severity of the CAD. In some cases, treatment was also influenced by individual patient preference. One hundred five patients underwent percutaneous transluminal coronary angioplasty (), including 5 patients who initially were treated by thrombolytic therapy for an acute episode of myocardial infarction. Indications for these procedures, preoperative clinical details, and a summary of the vessels revascularized are outlined in Tables 1 through 3. Multiple-vessel angioplasty was performed in only patients, and multiple-lesion angioplasty of a single vessel in 6 patients. In patients, although dilatation of the main lesion was achieved, revascularization was incomplete /94/$7.00

2 14 KAUL ET AL VERSUS IN OCTOGENARIA Ann Thorac Surg Angioplasty was considered successful when the residual luminal dimension was 50% or less on angiography and there was clinical improvement without any major cardiac event or complication within 1 month. Failure to achieve 50% or less residual stenosis, dissection, an acute closure of a dilated lesion, clot formation, and an urgent need for to restore coronary circulation were considered "failed". Angioplasty was performed to open an occluded vessel after an acute myocardial infarction (AMI) in 11 patients as an emergent procedure. It was performed as an urgent procedure in 48 and as an elective procedure in 46 patients (Table 4). Emergency was performed for acute myocardial infarction (n = 14). An urgent (n = 1) was performed mainly for unstable angina, or evolving acute or resolving myocardial infarction. Elective (n = ) was performed for stable class IV angina (see Table 4). A carotid Doppler scan was performed in all cases, with the exception of cases that required emergency conveyance to the operating theater. A detailed systemic assessment was made in all cases and a Swan-Ganz catheter was placed before the induction of general anesthesia in most patients. Standard cardiopulmonary bypass with moderate hypothermia and cold blood cardioplegia was used for all patients. Since January 1989, cardioplegia has been delivered using a combined antegrade and retrograde route (it was done by antegrade route only before then). Postoperatively, dobutamine, nitroglycerine, and lowdose dopamine infusions were used as needed to improve cardiac output and reduce systemic vascular resistance. Prolonged ventilatory support was used when patients had hemodynamic instability, chronic obstructive pulmonary disease, a respiratory complication, or suboptimal neurologic recovery. Postoperatively, these patients required careful monitoring for longer periods and additional support for rehabilitation. Follow-up was complete in all patients by the end of June All patients were sent a questionnaire and then, if necessary, were contacted by telephone. Statistical Analysis Values are expressed as the mean ± standard error of the mean. Paired data were compared by using Student's t test, Table 1. Indications for or Indication Unstable angina Acute myocardial infarction Recurrent angina after previous: Recurrent ventricular dysrhythmias Stable NYHA class IV angina (n = 5) n % (n = 5) n % o = coronary artery bypass grafting; NYHA = New York Heart Association; = percutaneous transluminal coronary angioplasty. Table 2. Preoperative Patient Characteristics Patient Characteristic Mean age (y) Female CAD risk factors Hypertension Diabetes Smoking Family history Hyperlipidemia Clinical presentation Unstable angina AMI Cardiogenic shock IABP Stable class IV angina NYHA class I-II III-IV Previous Previous Coronary angiography Left main disease 3-vessel disease 2-vessel disease I-vessel disease Ostial stenosis LVEF > > <0. Vessels revascularized Incomplete revascularization Hospital stay (days) Systemic disease Hypothyroidism COPD PVD Internal carotid stenosis Parkinsonism Dementia Organic brain syndrome Macular degeneration (n = 5) n % 82.4 ± ± ± (n = 5) n % 84 ± p Value < < < < <0.001 < < < <0.01 < <0.008 < < <0.01 and unpaired data and proportional differences were compared using either the J! or Fisher's exact test for univariate analysis. The influence of all preoperative variables (see ± ± AMI = acute myocardial infarction; = coronary artery bypass grafting; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; IABP = intraaortic balloon pump; LVEF = left ventricular ejection fraction; = not significant; NYHA = New York Heart Association; PVD = peripheral vascular disease.

3 Ann Thorac Surg 1994;58: KAUL ET AL 1421 VERSUS IN OCTOGENARIA Table 3. Early Results of in 5 Octogenarians" Failed Deaths No./No. of No./No. of Site of Lesions Vessels: % Patients: % Proximal 8/ / Peripheral (multilesion, 2/ / n = 6) Graft lesion 4/8 50 3/ Total 14/ / "One hundred thirty-one lesions were treated in 125 vessels (left main, 1; right osteal stenosis, 1; left anterior descending, 63; diagonal, 3; right coronary artery, 37; posterior descending, 1; circumflex coronary artery, 6; ramus intermedius, 2; obtuse marginals, 3; saphenous vein graft to right coronary artery, 6; and saphenous vein graft to the left anterior descending coronary artery, 2). = percutaneous transluminal coronary angioplasty. Tables 1-4), intraoperative variables (aortic cross-clamp time, bypass time, antegrade or retrograde cardioplegia), and postoperative variables on hospital mortality was examined using univariate analysis. Variables with a p value of approximately 0.1 or less were then entered into stepwise multivariate analysis. To detect independent predictors of hospital mortality after, the following variables were entered for the multivariate analysis: emergency, preoperative myocardial infarction, cardiogenic shock; left ventricular ejection fraction (LVEF) of 0. or less, triple-vessel CAD, hypertension, diabetes, chronic obstructive pulmonary disease, renal failure, and acute respiratory distress syndrome. Variables entered to detect independent predictors of hospital mortality after were failed resulting in acute myocardial infarction, emergency, graft, proximal coronary artery disease, female sex, congestive heart failure, preoperative acute myocardial infarction, and an LVEF less than or equal to 0.. The Cox proportional hazard model was used to detect independent predictors of late survival for the entire series (3 patients) as well as for both treatment modalities. The variables examined were: sex difference; presence or absence of hypertension; diabetes, chronic obstructive pulmonary disease; peripheral vascular disease; left main CAD; triple-vessel CAD; LVEF less than or equal to 0.; preoperative myocardial infarction; emergent, urgent, or elective revascularization; incomplete revascularization; postoperative myocardial infarction; and congestive heart failure. Actuarial analysis based on the Kaplan-Meier model was used to construct survival and event-free survival curves, which then were compared using Mantel's test. Statistical analysis was performed using Statistical Analysis Package (Stat Pac software); a p value of less than 0.05 was considered significant. Results Patient Characteristics Mean age for the entire series was 82 ± 0.7 years (range, to 92 years); 164 (54.2%) patients were female. In general, was preferred for patients with advanced CAD or multivessel disease and those with poor left ventricular function (see Table 2). As expected, a greater number of patients in the group had to be left with incomplete revascularization than in the group (p < ) (see Table 2). Overall hospital mortality was 8.57% after angieplasty and 5.85% after (not significant) (see Table 4). Hospital mortality for emergent revascularization by or was significantly higher than for urgent or elective revascularization within their own groups (see Table 4). Hospital mortality for elective revascularization by or was marginally greater than 2% (see Table 4). The influence of advancing age on mortality, morbidity, and longer-term survival in our medical center is outlined in Table 5. Patients less than years of age fared better than septuagenarians, who in turn fared better than did octogenarians. The failure rate for angioplasty was highest in octogenarians, but age had no influence on the initial success rate for the angioplasty in the remaining patients. The only independent predictor of hospital mortality after was acute myocardial infarction due to a failure of that procedure (p < 0.01). Other predictors of hospital mortality by univariate analysis were emergent and graft (Table 6). Multivariate analysis revealed that significant predictors of hospital mortality after were emergency (p < 0.001), preoperative acute myocardial infarction (p < 0.001), and an LVEF less than or equal to 0. (p < 0.001). Using univariate analysis alone, the predictors revealed were postoperative renal failure (p < ), triple-vessel CAD (p < 0.04), systemic hypertension (p < 0.01), and diabetes (p < 0.02) (Table 7). Morbidity and Complications The primary clinical and angiographic success rate for angioplasty was 88.7% (see Table 3). It was 89.75% for proximal lesions, 94.9% for peripheral lesions, and only 18% for total or subtotal occlusions (see Table 3). Overall Table 4. Hospital Mortality (n = 5) (n = 5) No. of No. of Procedure Deaths/No. % Deaths/No. % Emergent 3/ / Urgent No previous 2/40 3/88.4" 5.94" Previous 3/8 3/13 Elective 1/ b 2/ 2.2 b Total 9/ / a Comparison of emergent with urgent, I' < emergent with elective, I' < b Comparison of Elective = 3 to 7 days after cardiac catheterization, under stable conditions; Emergent = procedure performed within 1 to 6 hours after cardiac catheterization for cardiogenic shock or hemodynamic instability; Urgent = procedure performed within 48 hours after cardiac catheterization for impending or expanding ischemia (thallium scan) (these patients were maintained on intravenous heparin or nitroglycerin).

4 1422 KAULET AL VERSUS IN OCTOGENARIA Ann Thorac Surg Table 5. Influence of Age on Results of Revascularization (7/-7/93) With Backup for Operation Revascularization Result > y -79 Y < Y > Y -79 Y < Y No. of patients Hospital mortality (%) a b 1.6 c Early failure (%) d 4 Overall morbidity (%) e b 2 a Hospital stay (days) 14 :±: 1.5 1O:±:1.3 8:±: 2.6 7:±: 0.9 5:±: 0.6 3:±: year survival (%) d c a p < 0.001, comparison of -79 y with < y age group. b p < 0.05,comparison of > y with -79 y age group. C p < 0.01,comparison of -79 y with < y age group. d p < 0.01,comparison of > y with -79 y age group. e p < 0.001, comparison of > y with -79 y age group. f p < 0.05,comparison of -79 y with < y age group. = coronary artery bypass grafting; = percutaneous transluminal coronary angioplasty. morbidity due to postprocedural complications was higher after than after (54% versus 36.2%; p < 0.05) (Table 8). Incidence of major postoperative cerebrovascular accident was 1% after and 1.5% after (not significant), but the incidences of postoperative confusion and delirium clearly were higher after. Survivors after showed a significant improvement in their New York Heart Association class (3.2 ± 0.06 versus 1.5 ± 0.07; p < ). This improvement was also seen in patients with successful angioplasty (3 ± 0.9 versus 2.14 ± 0.1; p < 0.005). Late Deaths and Events Significant predictors of late mortality after (using the Cox model) were: preoperative myocardial infarction (p < ) and an LVEF less than or equal to 0. (p < ). Late mortality in the group was predominantly due to cardiac events (17/40) and less frequently due to coexistent systemic disorders (respiratory, 8/40; malignant disease, 3/40; cerebrovascular accident, 2/40; and multiorgan failure, /40). Late mortality after was mainly due to noncardiac events (eg, pneumonia, 4/24; cerebrovascular accident, 3/24; ruptured esophagus, 1/24; carcinoma of the esophagus, 3/24; chronic renal failure, 4/24). The remaining deaths were cardiac related. Actuarial survival rates at 1 month and 1, 3, 5, and years after were 94%, 89%, 77%, 66%, and 42%, respectively; after they were 91 %, 88%, 83%, 55%, and 21 %, respectively. The difference in survival curves between the two treatment modalities remained significant beyond 5 years (Fig 1). However, at 3 years postopera- Table 6. Predictors of Hospital Mortality in Octogenarians After Predictor Failed Emergent Graft = not significant; angioplasty. x Univariate p Value < <0.02 <0.01 Multivariate p Value <0.001 percutaneous transluminal coronary tively, cardiac event (cardiac death, redo,, myocardial infarction, and class IV angina) free survival was 81 % after and 61 % after (p < 0.01) (Fig 2). Of the 24 of 96 (25%) survivors after in whom restenosis developed, 14 underwent a repeat at an interval of 11 ± 2.4 months and underwent at an interval of 12 ± 8.4 months postoperatively (see Table 4). In the subset of patients requiring as an emergent procedure (Fig 3), patients with an LVEF less than or equal to 0. (Fig 4) and with preoperative acute myocardial infarction (Fig 5) had a high perioperative mortality and diminished long-term survival. Comment Recent United States population statistical surveys project a disproportionate growth in the octogenarian sector [2]. It is obvious that a number of octogenarians will present with clinical symptoms and complications of ischemic heart disease, which remains a principal cause of death in this age group [4]. The demographic and disease pattern of CAD in this age group may show interesting variation [7-]. In this series, as well as in previous reports, women comprised a greater proportion of CAD patients than Table 7. Predictors of Hospital Mortality in Octogenarians After Univariate Multivariate Predictor X 2 p Value p Value Emergency 14 <0.001 <0.001 Preop AMI 9.2 <0.008 <0.001 LVEF < < <0.001 Postop renal failure 50 < Redo 7.47 <0.01 Triple-vessel CAD 5.8 <0.04 Hypertension 5.6 <0.04 Diabetes 5.4 <0.02 AMI = acute myocardial infarction; = coronary artery bypass grafting; CAD = coronary artery disease; LVEF = left ventricular ejection fraction; = not significant; Postop ~ postoperative; Preop = preoperative.

5 Ann Thorac Surg KAUL ET AL 1423 VERSUS IN OCTOGENARIA Table 8. Incidence of Major Complications or Events After or in Octogenarians (n = 5) (n = 5) P Complication/Event n % n % Value Cardiac Respiratory <0.001 Gastrointestinal Renal failure Neurologic Major CVA Others Wound infections Overall morbidity = coronary artery bypass grafting; CVA = cerebrovascular accident; = not significant; = percutaneous transluminal coronary angioplasty. expected []. Owing to a general reluctance to use invasive procedures in this population of fragile individuals, ischemic heart disease often is allowed to progress to an advanced stage. A number of previous studies have shown a greater incidence of left main disease, triple-vessel CAD, ventricular dysrhythmias, and dysfunction in this age group [9, 11]. In view of advanced CAD, multisystem disorders, and diminished vital organ function reserves, these individuals are less capable of withstanding the stress of major interventional procedures [5]. Therefore, less extensive procedures such as thrombolytic therapy and angioplasty often have been considered more attractive options, although not as beneficial or as lasting as coronary artery bypass [12]. Thrombolytic therapy has been used successfully to thwart an acute ischemic episode, but its early patency rate clearly is inferior to that obtained after a successful angioplasty [13]. Thrombolytic therapy also carries a risk of hemorrhagic episodes, especially cerebrovascular accidents [131, and for this reason [14] it was not used frequently in this series. Data regarding the use and the success of angioplasty in this age group are limited, and very few studies have evaluated the long-term results of the invasive treatment strategies. Angioplasty clearly gives better results than thrombolytic therapy in an acute situation and has been preferred if available [13]. However, previous reports have demonstrated a % to 35% closure rate within 6 months after a successful [7, 15]. It is generally the most suitable therapeutic option for singlevessel disease [7]. A single-vessel angioplasty was performed in.95% of our patients, which is comparable with another recently published series [12]. Little and associates [] have reported a 96% success rate for multiple-lesion, single-vessel angioplasty. In two recent reports, multiple angioplasty was attempted in almost one-third of the patients [6, 15]. In octogenarians, the primary clinical and angiographic success rate of has been lower than in younger patients. In our series the primary clinical as well as the angiographic success rate after was 88.7%, which was within the range (74%-93%) for this age group [12, 15]. Primary success after angioplasty also depends on the anatomic site and the characteristics of the lesions. Earlier reports showed a lower success rate for circumflex than for right or left anterior descending artery lesions []. In general, left main coronary stenosis, ostial stenoses, and more proximal lesions have a lower success rate than do more peripheral lesions. As in other age groups, graft stenoses in general are expected to have a lower success rate than primary lesions. In our series, primary success for the proximal lesions (89.75%) was inferior to that for the more peripheral lesions (94.9%) and right coronary arterial lesions had a marginally lower primary success rate than other vessels. In our series, acute myocardial infarction due to failed developed in 7.6% and required emergency operation, which was within the range (2.7% to 7.8%) described earlier [7]. Twenty-five percent of our patients 0 0/0 Survival CASG L.-,...,.-,...,...,.""T"""T"""T'""T'"'T"""'T"""'T"""'T""T""T"",...,...T"'""T"'""T"'""r-,...,..,...,... PlCA Fig 1. Actuarial survival ± % confidence limits after coronary artery bypass grafting () versus percutaneous transluminal coronary angioplasty () in octogenarians. (CL = confidence limit; OP = operaiioe.)

6 1424 KAUL ET AL VERSUS IN OCTOGENARIA Ann Thorac Surg Fig 2. Cardiac event-freesurvival (freedom from further coronary artery bypass grafting (), percutaneous transluminal coronary angioplasty (), myocardial infarction, or death) for versus. Cardiac Event Free % Survival ~ P T C A PlCA had early stenosis after successful angioplasty, as described earlier [7, 15]. Recent reports indicate that although coronary artery bypass operation in octogenarians generally was performed for more advanced disease [61, it clearly resulted in longer survival [7] and longer symptomatic relief than did angioplasty [7]. In our similar experience, hospital mortality after was no higher than after angioplasty. Some authors have reported a clearly lower perioperative mortality for than for [61, but in general, most reports indicate that perioperative mortality after both procedures ranges between 2% and % [4, 11, 12, 14-17]. These invasive procedures were associated with higher mortality when they were performed for unstable angina, acute myocardial infarction, or cardiogenic shock. However, it appears that when elective was performed in octogenarians who were stable preoperatively, the perioperative mortality ranged between 2% and 3% [4]. Due to the severe nature of the coronary artery disease and the presence of a number of coexisting disorders, 43% to 75% of the survivors after have been known to experience some postoperative complication [11, 17]. Some of these may have contributed to the high mortality of 15% to 41% within 3 months after [11, 17]. As reported earlier [6] the survival difference before 5 years between the and groups was almost negligible, but the cardiac-related event-free survival rate at that interval was clearly superior after. As described by others [4, 5, 16] the important predictors of perioperative mortality in this series were: emergency, an LVEF of 0., and operation for acute myocardial infarction. Others have reported reintubation and ventilation [17], ventricular dysrhythmias, and reexploration for bleeding [5] as important predictors of perioperative mortality after. In this series only 2 patients were explored for postoperative hemorrhage after, and both survived. Gentle handling of the tissues and meticulous hemostasis are absolutely essential for a smooth postoperative recovery in this Fig 3. Cumulative survival of octogenarians requiring emergency coronary artery bypass grafting () versus nonemergency up to years. A risk factor of emergent was not significant using the Cox hazard model due to small numbers. 0 % Survival 50 40, EMERGENCY -- URGENT I ELECTIVE

7 Ann Thorac Surg 1994;58: KAUL ET AL 1425 VERSUS IN OCTOGENARIA % Survival lvefs. -- lvef>% Deaths lvef<% - l V E F ~ 3 0 % HAZARD RA TE X 00 (:I: % cc) A j l B 1j l2 1 ~ Fig 4_ (A) Cumulative survival ± % confidence limits of the subset of patients with a left ventricle ejection fraction of 0. or less (LVEF) requiring coronary artery bypass grafting () versus other patients. (B) Subset of patients with LVEF <0. had a higher cardiac-related death rate in perioperative period and later (6-7 years). (CL = confidence limits.) age group. In our series the most important predictor of hospital mortality after was acute myocardial infarction after a failed procedure. The incidence of failure and postprocedure acute myocardial infarction is generally higher in this age group (ranging between 1% and 7.8%) than in younger patients []. It is our impression that invasive procedures such as and sometimes are postponed beyond the appropriate time in octogenarians out of fear for their age and fragility. In our series, elective was performed in 45% and elective in 43.8%, before they suffered a significant deterioration in New York Heart Association class. Late intervention in these fragile patients with diminished reserves likely accounts for higher mortality and morbidity. Patient selection for or generally is guided by the severity of the coronary artery disease and lesion characteristics. In this age group especially, individual patient preference for one or the other treatment modality is also given important consideration. With a progtessive improvement in technique, angioplasty has % Survival PRE OP AMI -- WITHOUT AMI Deaths WITH PRE OP ACUTEMI -- WITHOUT AMI HAZARD RATE X 00 (:t % ClI A ~l ts s 8 9 B Fig 5. (A) Cumulative survival ± % confidence limits of the subset of octogenarians who required coronary artery bypass grafting () for acute myocardial infarction (AMI) versus the remaining patients. (B) The subset of octogenarians requiring for acute myocardial infarction (MI) had a higher perioperative and late mortality than the remaining patients. (CL = confidence limits.)

8 1426 KAUL ET AL VERSUS IN OCTOGENARIA Ann Thorac Surg been performed successfully for multiple-vessel disease and for more proximal and difficult lesions. However, % to 35% of vessels may have restenosis within 6 months after angioplasty [7, 15]. Although the incidence is not directly related to old age, this has been considered as a significant disadvantage of this procedure. Coronary artery bypass operation was preferred in twothirds of our patients. We did not use thrombolytic therapy due to a higher risk of stroke associated with it for this age group [18]. Early intervention may reduce perioperative mortality in these patients, but postoperative morbidity is likely to remain high, demanding a greater amount of care for a successful outcome after operation. We believe this approach could help a number of octogenarians who lead an independent existence and are expected to live for another 7 to 8 years [19], after having reached years of age. This study shows that octogenarians may receive substantative benefits through myocardial revascularization, especially with. As expected, myocardial revascularization did not improve the quality of life of our octogenarians to the same extent that it did for our younger patients. Recently, we have extended the use of multivessel and multilesion angioplasty to more discrete and peripheral lesions, especially for patients with retarded physical and mental capabilities and for patients with uncompensated medical illness. We prefer for patients with complex coronary anatomy in patients with well-compensated medical conditions. We are grateful to Mrs Sandra Siebert for completing the list of octogenarians and also to Ms Melody Hamrick for secretarial help in preparation of the manuscript. References 1. US Bureau of the Census: statistical abstract of the United States 19, ed 1. Washington, DC: US Government Printing Office. 2. Bureau of Census. Projection of the population of the United States by age, sex and race, Washington, DC: Government Printing Office, 1984:Current Population Series P-25 No National nursing home survey. Hyattsvik MS: National Center for Health Statistics, Ko W, Gold JP, Lazzaro R, et a1. Survival analysis of octogenarian patients with coronary artery disease managed by elective coronary artery bypass surgery versus conventional medical therapy. Circulation 1992;86(Suppl 2): Ko W, Krieger KH, Lazenby WD, et a1.coronary artery bypass grafting in one hundred consecutive octogenarian patients. J Thorac Cardiovasc Surg 1991;2: Mick MJ, Simpfendorfer C, Arnold AZ, Piedmonte M, Lytle BW. Early and late results of coronary angioplasty and bypass in octogenarians. Am J Cardiol 1991;68: Gold S, Wong WF, Schatz II, Blanchette PL. Invasive treatment for coronary artery disease in the elderly. Arch Int Med 1991;151: Naunheim KS, Kern MI, McBride LR. Coronary artery bypass surgery in patients aged years or older. Am J Cardiol 1987;59: Gersh BI, Kronmal RA, Frye RL, et a1.coronary arteriography and coronary artery bypass surgery morbidity and mortality in patients over 65 years and older: a report from CASSo Circulation 1983;67: Little T, Milner M, Pichard AD, Mukherjee D, Lindsay J Jr. A comparison of multi-lesion percutaneous transluminal angieplasty in elderly patients over years and younger subjects. Am Heart J 1991;122: Mullany CJ, Darling GE, Pluth JR, Orzulak TA, Schaff HV. Early and late results after isolated coronary artery bypass surgery in 159 patients aged years and older. Circulation 19;82(SuppI4): Santana JO, Haft JI, La Marche, Goldstein JE. Coronary angioplasty in patients eighty years or older. Am Heart J 1992;124: Pringle SD, Boon NA. Immediate coronary angioplasty for acute myocardial infarction, safe and effective but not available in most centers. Br Med J 1993;6: Rich MW, Sandza JG, Kleiger RE, Connors JP. Cardiac operation in patients over years of age. J Thorac Cardiovasc Surg 1985;: [eroudi MO, Kleiman, Monor ST. Percutaneous transluminal coronary angioplasty in octogenarians. Am J Intern Med 19;113: Tsai TP, Nessim S, Kass RM. Morbidity and mortality after coronary artery bypass in octogenarians. Ann Thorac Surg 1991;51: Edmunds LH, Stephenson LW, Edie RN, Ratcliffe MB. Open heart surgery in octogenarians. N Engl J Med 1988;319: The Gusto Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329: National Center for Health Statistics United States Life Tables: US decennial life tables for 1979 to Vol 1, No. 1. Washington, DC: Government Printing Office, 1985:Duss Publication NO (Phs)