Still puzzling: Best care for the frail and elderly with coronary artery disease

Researchers found that with all else being equal, the risk of death was highest for the medically managed group and lowest for patients who underwent stenting. Death rates among medically managed patients increased rapidly during the first three months following release from the hospital, and stayed higher than those in the other two groups. At one year, the mortality rate among the medically managed group was 7.7 percent, 3.6 percent for patients who underwent stenting, and 6.2 percent among those who underwent bypass procedures.

"It is important to know that the patients in the medically managed group had a higher death rate despite receiving most of the currently recommended medications for this condition from clinical practice guidelines," says Roe. "There are often very good reasons why stenting or bypass are not viable options for some patients. What this study tells us is that for these patients who are medically managed, we need to come up with better treatment approaches that lessen their risk of death."

Roe says possible solutions may arise from a new trial that is just getting under way. The new study, called TRILOGY will compare clopidogrel (Plavix) with the experimental drug prasugrel, another anti-clotting agent, among elderly and frail medically-managed patients with chest pain and coronary artery disease. An earlier trial found that prasugrel was effective in reducing the risk of clotting, but it also brought about a higher risk of bleeding. The TRILOGY trial will compare the two drugs again, but will study a lower dose of prasugrel than in the earlier study. The Duke Clinical Research Institute will manage TRILOGY, which is expected to enroll approximately 10,000 patients in hundreds of hospitals world-wide.

Colleagues from the Duke Clinical Research Institute who contributed to the published study include Mark Chan, Kenneth Mahaffey, Lena Sun, Karen Pieper and Robert Califf. Co-authors from other institutions include Harvey White, from Aukland City Hospital, New Zealand; and Philip Aylward and James Ferguson from the Texas Heart Institute.

The SYNERGY trial was funded by Sanofi-Aventis.