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Association of Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention With Memory Decline in Older Adults Undergoing Coronary Revascularization

Educational Objective
To understand the association of memory decline and coronary revascularization.
1 Credit CME
Key Points

Question  Among older adults undergoing coronary revascularization, is the type of procedure (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) associated with differences in memory decline over time?

Findings  In this retrospective cohort study of 1680 US older adults, the change in the rate of memory decline from pre- to postprocedure was not significantly different for those undergoing CABG vs PCI.

Meaning  There was no significant difference in the change in the rate of memory decline after CABG compared with PCI in a cohort of older adults.


Importance  It is uncertain whether coronary artery bypass grafting (CABG) is associated with cognitive decline in older adults compared with a nonsurgical method of coronary revascularization (percutaneous coronary intervention [PCI]).

Objective  To compare the change in the rate of memory decline after CABG vs PCI.

Design, Setting, and Participants  Retrospective cohort study of community-dwelling participants in the Health and Retirement Study, who underwent CABG or PCI between 1998 and 2015 at age 65 years or older. Data were modeled for up to 5 years preceding and 10 years following revascularization or until death, drop out, or the 2016-2017 interview wave. The date of final follow-up was November 2017.

Exposures  CABG (including on and off pump) or PCI, ascertained from Medicare fee-for-service billing records.

Main Outcomes and Measures  The primary outcome was a summary measure of cognitive test scores and proxy cognition reports that were performed biennially in the Health and Retirement Study, referred to as memory score, normalized as a z score (ie, mean of 0, SD of 1 in a reference population of adults aged ≥72 years). Memory score was analyzed using multivariable linear mixed-effects models, with a prespecified subgroup analysis of on-pump and off-pump CABG. The minimum clinically important difference was a change of 1 SD of the population-level rate of memory decline (0.048 memory units/y).

Results  Of 1680 participants (mean age at procedure, 75 years; 41% female), 665 underwent CABG (168 off pump) and 1015 underwent PCI. In the PCI group, the mean rate of memory decline was 0.064 memory units/y (95% CI, 0.052 to 0.078) before the procedure and 0.060 memory units/y (95% CI, 0.048 to 0.071) after the procedure (within-group change, 0.004 memory units/y [95% CI, −0.010 to 0.018]). In the CABG group, the mean rate of memory decline was 0.049 memory units/y (95% CI, 0.033 to 0.065) before the procedure and 0.059 memory units/y (95% CI, 0.047 to 0.072) after the procedure (within-group change, −0.011 memory units/y [95% CI, −0.029 to 0.008]). The between-group difference-in-differences estimate for memory decline for PCI vs CABG was 0.015 memory units/y (95% CI, −0.008 to 0.038; P = .21). There was statistically significant increase in the rate of memory decline after off-pump CABG compared with after PCI (difference-in-differences: mean increase in the rate of decline of 0.046 memory units/y [95% CI, 0.008 to 0.084] after off-pump CABG), but not after on-pump CABG compared with PCI (difference-in-differences: mean slowing of decline of 0.003 memory units/y [95% CI, −0.024 to 0.031] after on-pump CABG).

Conclusions and Relevance  Among older adults undergoing coronary revascularization with CABG or PCI, the type of revascularization procedure was not significantly associated with differences in the change of rate of memory decline.

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Article Information

Corresponding Author: Elizabeth L. Whitlock, MD, MSc, Department of Anesthesia & Perioperative Care, University of California, San Francisco, Box 0648, 521 Parnassus Ave, Floor 04, San Francisco, CA 94143 (elizabeth.whitlock@ucsf.edu).

Accepted for Publication: March 19, 2021.

Author Contributions: Dr Whitlock and Ms Diaz-Ramirez had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Whitlock, Covinsky, Avidan, Glymour.

Acquisition, analysis, or interpretation of data: Whitlock, Diaz-Ramirez, Smith, Boscardin, Glymour.

Drafting of the manuscript: Whitlock.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Whitlock, Diaz-Ramirez, Boscardin, Glymour.

Obtained funding: Whitlock.

Supervision: Smith, Avidan.

Conflict of Interest Disclosures: Dr Whitlock reported receiving grants from the National Institutes of Health (NIH) (National Institute on Aging [NIA]). Ms Diaz-Ramirez reported receiving grants from the NIH (NIA). Dr Smith reported receiving grants from the NIH (NIA) and the National Palliative Care Research Center. Dr Boscardin reported receiving grants from NIH (NIA, National Institute of Mental Health [NIMH], National Institute of Neurological Disorders and Stroke, National Center for Advancing Translational Sciences), the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, and the Centers for Disease Control Foundation. Dr Covinsky reported receiving grants from the NIH (NIA). Dr Avidan reported receiving grants from the NIH (National Institute of Nursing Research, NIMH, NIA, National Institute of General Medical Sciences, National Heart, Lung, Blood, and Institute), the Bill & Melinda Gates Foundation and the COVID-19 Therapeutics Accelerator. Dr Glymour reported receiving grants from the NIH (NIA, National Institute on Minority Health and Health Disparities, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute on Alcohol Abuse and Alcoholism) and the Robert Wood Johnson Evidence for Action Program.

Funding/Support: Funding was provided by the National Institute on Aging (grant P30AG044281 to Drs Whitlock, Smith, Boscardin, and Covinsky and Ms Diaz-Ramirez; grant R03AG059822 to Dr Whitlock and Ms Diaz-Ramirez; and grants R01AG057751 and K24AG068312 to Dr Smith) and the National Center for Advancing Translational Sciences (grant KL2TR001879 to Dr Whitlock and Ms Diaz-Ramirez), both of the National Institutes of Health, and the Foundation for Anesthesia Education and Research (to Dr Whitlock).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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