Turning 80 lowers odds heart attack patients will get bypass surgery

(Reuters Health) - Age, they say, is just a number. But when someone turns 80, their chance of getting life-saving bypass surgery to treat a heart attack immediately drops by 24%, according to a new study.

Researchers found that while 7.0% of 4,426 heart attack patients who were age 79 and only two weeks from their 80th birthday got bypass surgery, the rate dropped significantly to only 5.3% for 5,036 people who were just 2 weeks past their 80th birthday - even though the health of people in both groups was essentially the same.

That, in turn, translated to a higher death rate among the 80-year-olds over the 30 and 60 days following their heart attacks, according to the report in The New England Journal of Medicine.

Doctors “are arbitrarily classifying the two groups of patients as young versus old instead of treating them as two groups who are basically the same age,” coauthor Dr. Anupam Jena, an associate professor of healthcare policy and medicine at Harvard University Medical School in Boston, told Reuters Health in a telephone interview.

“It’s an important observation,” said Dr Richard Becker, director of the Heart, Lung and Vascular Institute at the University of Cincinnati College of Medicine, in Ohio, who was not involved in the study. “We don’t want to exclude someone from a procedure that could be potentially life-saving.”

Becker told Reuters Health by phone that doctors should be relying on decision making tools that help predict the success of such surgery, such as the scoring system developed by the Society for Thoracic Surgeons, in which age is not a factor.

Jena said patients and families need to be aware of the bias when doctors are recommending treatment options, and encourage doctors to look beyond patients’ chronological age “because their biological age may be very different.”

The decision to exclude more 80-year-olds from bypass surgery appears to stem from an unconscious habit, Jena’s team concludes. The moment the first digit of a person’s age changes from a 7 to an 8, doctors start to lump them in with patients who are well into their 80s.

Such bias reflects the natural but irrational tendency to inflate the importance of the first digit of a number, Jena explained, such as when consumers are drawn to an item priced at $4.99 instead of the same item priced at $5.00. That extra penny takes on a disproportionate importance, one not seen when consumers compared two items priced, for example, at $4.98 and $4.99.

“It’s something that affects people’s decisions in a subconscious way,” Jena said. But when applied to the age of a heart attack victim who might benefit from bypass surgery, “this is shifting doctor’s decisions on a serious medical decision.”

This is not the first study to demonstrate that type of bias in medicine.

Research published in 2017 by another of the current study’s authors, Stephen Coussens of Columbia University’s Mailman School of Public Health in New York City, found that if you arrived at the emergency department just after your 40th birthday, you were roughly 10% more likely to be tested for heart disease and 20% more likely to be diagnosed with heart disease than if you were only a few weeks away from your 40th.

The bypass findings are based on seven years of Medicare data, which also showed that turning 80 didn’t reduce a person’s chances of successful bypass surgery.

But it did have an impact on death rates. The 30-day mortality rate after hospitalization for heart attack was 17.7% for those just shy of their 80th and 19.8% for patients admitted within two weeks after their 80th.

A similar increase was seen at 60 days, but after one year the effect had faded.

To double-check their findings, the Jena team compared the odds of getting bypass two weeks before and after other birthdays. They found no similar dropoff for ages 77, 78, 79, 81, 82 or 83.

Bypass surgery is not the only way to re-open coronary arteries after a heart attack. In a procedure known as stenting, doctors unclog the artery and place a small metal tube, or stent, to hold it open. The current study didn’t look at whether patients who didn’t get surgery got stents instead.

SOURCE: The New England Journal of Medicine, online February 19, 2020.