September 3, 2012 | 3
Astronaut Neil Armstrong died August 25th, following complications from a cardiovascular procedure on August 7th, according to a statement from his family. Reportedly, Mr. Armstrong had failed a cardiac stress test on August 6th, prompting an urgent four vessel coronary artery bypass graft surgery (CABG).
Some have questioned whether such surgery is appropriate in an octogenarian. While no one has released information specific to Mr. Armstrong’s case, we can look at broader data regarding cardiac surgery. Over all, elderly (>80 years old) do have a higher risk of complications and death, but that relates to their general state of health—whether or not they are diabetic, for example, or have chronic renal failure or similar illnesses, known as “comorbidities.”
Among those >65 years of age, mortality data among 348,341 patients was 3.2 percent at 30 days, 6.4 percent at 180 days, 8.1 percent at one year, 11.3 percent at two years, and 23.3 percent at three years, by a Kaplan-Meier analysis.
The 2011 practice guidelines from the American College of Cardiology Foundation/American Heart Association Task Force (ACCF/AHA) note an operative mortality that varies from 2.6% to 11% (the latter being >80 years old and undergoing urgent or emergency surgery). These numbers did not distinguish between subgroups with differing comorbidities. But despite the higher morbidity (complications) and mortality (death), most of the octogenarians showed functional improvement after CABG.
One single center study showed elderly patients had a slower recovery from surgery but no difference in the improvement of angina or quality of life by one year post surgery than younger ones. In another study of more ill octogenarians undergoing CABG with and without aortic valve replacement, with 66% having significant congestive heart failure, follow-up at an average of 2.1 years showed “81% were not or little disabled in their daily activity…93% were free or considerably less symptomatic.”
Age does not appear to be an absolute contraindication to surgery for coronary artery disease—rather, outcome is determined, in large part, by the person’s other illnesses and general state of health.
In contrast, heart transplants more commonly have 70 years as an age cutoff, prompting some raised eyebrows when Dick Cheney, age 71, received a transplant earlier this year. A limited study suggested that here, too, the underlying health of the patient determines the outcome.
To my mind, those who suggest “Heart Surgeons Kill First Man on the Moon” are behaving irresponsibly. Whether—and how urgently—surgery needs to be done depends on the specifics of a case. For example, critical proximal occlusion of the left main or left anterior descending (LAD) coronary artery is known as the “widow-maker” and does require urgent surgical intervention, as this artery perfuses the bulk of the heart. More diffuse or distal disease is most commonly treated medically and this, too, is supported by data. If coronary artery disease is stable, then a recent meta-analyis suggests that medical therapy is as successful as surgical intervention.
There are complications with any surgery, including bleeding, blood clots, and post-op wound infections. We shouldn’t presume to second-guess the difficult choice that faced Mr. Armstrong and his family, nor add to their grief. Instead, we should remember his bravery, his humility, and his family’s request, “Honor his example of service, accomplishment and modesty, and the next time you walk outside on a clear night and see the moon smiling down at you, think of Neil Armstrong and give him a wink.”
Coronary arteries image – Gray’s Anatomy/Wikimedia
Neil Armstrong – NASA/Wikimedia
Blue Moon – NASA/MSFC NASA blog
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