What is the best approach for a woman in her 60s with three or more blocked arteries?

Management of Three or More Blocked Arteries in a Woman in Her 60s

For a woman in her 60s with three-vessel coronary artery disease, coronary artery bypass grafting (CABG) is the recommended revascularization strategy, particularly if she has reduced left ventricular function (LVEF <50%) or diabetes, as CABG provides superior long-term survival and reduced cardiovascular events compared to percutaneous coronary intervention (PCI) in this anatomic context. 1, 2

Initial Risk Stratification and Clinical Presentation

The management approach depends critically on whether the patient presents with:

• Acute coronary syndrome (unstable angina/NSTEMI): Requires early invasive strategy with coronary angiography within 24-48 hours if high-risk features are present (elevated troponins, recurrent ischemia, hemodynamic instability) 1, 3
• Chronic stable angina: Allows for elective evaluation and revascularization planning based on symptom severity, extent of ischemia, and comorbidities 1

Women with elevated biomarkers (troponin, BNP, or CRP) benefit significantly from invasive therapy, whereas low-risk women without elevated biomarkers may experience harm from early invasive approaches. 1

Revascularization Strategy Selection

CABG is Preferred When:

• Three-vessel disease with reduced left ventricular ejection fraction (<50%): CABG demonstrates clear survival advantage over medical management alone 1, 2
• Diabetes mellitus with multivessel disease: CABG provides improved survival and reduced cardiovascular events compared to PCI 1, 3
• Complex multivessel coronary artery disease: CABG results in more complete revascularization than PCI 3, 4
• Left main disease in addition to multivessel involvement 1, 3

PCI May Be Considered When:

• Patient has increased frailty or active comorbidities: The least invasive procedure is recommended in highly symptomatic patients with increased frailty 1
• Patient refuses CABG surgery: Though this represents suboptimal management for three-vessel disease 1

Special Considerations for Women in Their 60s

Age-Related Factors:

• Diagnostic and revascularization decisions should be based on symptoms, extent of ischemia, frailty, life expectancy, and comorbidities 1
• Drug-eluting stents (DES) are recommended if PCI is chosen 1
• Radial access is recommended to reduce access-site bleeding complications 1
• Particular attention must be paid to drug side effects, intolerance, and overdosing 1

Sex-Specific Considerations:

• Weight-based and renally-adjusted dosing of antiplatelet and anticoagulant agents is essential to reduce bleeding risk in women 1
• Hormone replacement therapy is NOT recommended for risk reduction in post-menopausal women 1

Medical Management Framework

Mandatory Pharmacotherapy:

• ACE inhibitors: Recommended for event prevention in coronary artery disease 1
• High-intensity statin therapy: For all patients with coronary disease 5, 3
• Antiplatelet therapy: Aspirin indefinitely; dual antiplatelet therapy (DAPT) duration depends on revascularization strategy 1, 5
• Beta-blockers: For symptom control and secondary prevention 1

Risk Factor Control:

• Blood pressure, LDL-cholesterol, and HbA1c control to target values is mandatory 1
• If diabetes is present, consider SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) or GLP-1 receptor agonists (liraglutide or semaglutide) 1

Timing Algorithm for Revascularization

If CABG is Selected:

1. Optimize medical therapy pre-operatively
2. Stop clopidogrel approximately 5 days before surgery if operation can be safely deferred 3
3. Continue aspirin perioperatively
4. Allow 7-14 days post-CABG for surgical recovery before any subsequent procedures 2

If PCI is Selected:

1. Use drug-eluting stents in elderly patients 1
2. Maintain DAPT for at least 12 months post-PCI 1, 5
3. Consider staged procedures for complex multivessel disease rather than attempting complete revascularization in single session

Critical Pitfalls to Avoid

• Do not use PCI as default strategy for three-vessel disease with reduced ejection fraction or diabetes: This results in inferior outcomes compared to CABG 1, 2, 3
• Do not perform early invasive strategy in low-risk women without elevated biomarkers: This may cause harm including increased bleeding risk 1
• Do not neglect renal function assessment: Estimate creatinine clearance and adjust doses of renally cleared medications; minimize iodinated contrast in severe chronic kidney disease 1
• Do not overlook bleeding risk assessment: Anticoagulant and antiplatelet therapy should be weight-based and adjusted for chronic kidney disease 1

Quality of Life Considerations

Elderly patients aged 75 years or older with angina despite standard drug therapy benefit more from revascularization than from optimized medical therapy in terms of symptom relief and quality of life. 6 This finding likely extends to women in their 60s with three-vessel disease, particularly those with limiting symptoms despite optimal medical management.