Avoiding revascularization in cancer patients with severe coronary artery disease: what to expect?

Introduction and Purpose Cancer patients with severe coronary artery disease (CAD) pose important management challenges, particularly when revascularization is not undertaken. Evidence describing the natural history and outcomes of medically managed severe CAD in oncology populations remains limited. This study aims to characterize the clinical profile and long-term outcomes of cancer patients with severe CAD treated exclusively with optimal medical therapy. Methods A retrospective cohort study was performed including cancer patients who underwent coronary angiography between 2017 and 2022. Patients with severe CAD managed medically rather than with PCI or CABG were identified. Demographic, cardiovascular, oncologic, laboratory, and angiographic characteristics were extracted from electronic records. Follow-up began at angiography, and predefined outcomes included all-cause and cardiovascular mortality, acute coronary syndromes (ACS), repeat angiography, revascularization, and major bleeding. Results Among 318 cancer patients who underwent angiography, 53 had severe CAD managed medically. The cohort was elderly (mean age 77 ± 7), predominantly male, and presented with a substantial burden of cardiovascular comorbidities. Genitourinary (44%) and gastrointestinal (24%) cancers were most frequent. Functional status was generally preserved, with 70% ECOG 0–1, while 24% had stage IV disease. Nearly half (45%) underwent angiography for ACS. Cardiovascular risk factors were prevalent: hypertension (93%), diabetes (40%), dyslipidemia (68%), smoking history (51%), prior MI (26%), prior PCI (26%), and chronic kidney disease (51%). Severe multivessel CAD was common, involving the LAD (54%), circumflex (58%), and RCA (61%). Despite angiographic severity, ischemic complications were infrequent: 4 patients (7.5%) developed ACS, 6 (11.3%) required repeat angiography, and 2 (3.8%) underwent revascularization. Major bleeding occurred in two patients. Overall mortality reached 63%. Among the 35 deaths with a documented cause, non-cardiovascular mortality predominated (74%), whereas cardiovascular causes accounted for 26%, indicating outcomes were largely driven by cancer-related or other non-cardiac conditions rather than CAD progression. Conclusion In cancer patients with severe CAD managed conservatively, long-term survival is poor and primarily shaped by non-cardiovascular mortality. Recurrent ischemia, repeat angiography, and revascularization were uncommon, suggesting that in selected oncology patients a conservative strategy may be appropriate, as prognosis depends mainly on the underlying malignancy.