1. In this randomized controlled trial, in older adults with non-ST-segment elevation myocardial infarction (NSTEMI), invasive treatment did not significantly reduce the composite risk of cardiovascular death or nonfatal MI compared to conservative treatment.
2. There were fewer occurrences of fatal or nonfatal MI in patients in the invasive-strategy group than in the conservative-strategy group.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Advancing age is an established risk factor for NSTEMI. Despite this, older adults have been repeatedly underrepresented in clinical trials; consequently, no established treatment guideline remains for this population. To date, the small number of clinical trials investigating the use of invasive treatment in older adults with NSTEMI have yielded conflicting results; some suggest its superiority, while others negate this claim. Furthermore, the poor characterization of frailty, cognitive capabilities, and coexisting conditions in older adults within these studies limits their generalizability. This study aims to evaluate the effectiveness of a routine invasive approach to NSTEMI in older adults compared to best-standard medical treatment in a study population representative of the general public. The results indicate that invasive therapy does not significantly lower the composite risk of cardiovascular death or nonfatal MI. However, while not statistically significant, patients treated with an invasive strategy had fewer occurrences of fatal or nonfatal MI or stroke and required fewer coronary angiography or revascularization interventions. Conversely, the invasive-strategy group experienced higher rates of all-cause death, non-cardiovascular death, transient ischemic attacks (TIAs), and bleeding that required medical attention. This study had several limitations, including a smaller sample size than initially planned due to recruitment challenges during COVID-19. Overall, the findings suggest that invasive treatment is not superior to the best medical practices for managing NSTEMI in older adults.
Click here to read the study in NEJM
Relevant Reading: Invasive versus Conservative Strategy for Older Patients with Myocardial Infarction
In-Depth [randomized controlled trial]: This randomized controlled trial investigated whether an invasive treatment strategy is superior to a conservative strategy for the management of NSTEMI in older adults. The invasive strategy included coronary angiography with possible coronary revascularization in addition to the best medical practices, while the conservative approach involved the best medical practices alone. Patients were eligible if they were over 75 years old with a confirmed NSTEMI diagnosis. Exclusion criteria included a diagnosis of STEMI, unstable angina, or cardiogenic shock; a life expectancy under one year; prior participation in the SENIOR-RITA trial; or an inability to undergo coronary angiography. A total of 753 patients were randomized to the invasive strategy and 765 to the conservative strategy. The primary outcome was time to a composite event of cardiovascular death or nonfatal MI. Over a median follow-up of 4.1 years, 25.6% of patients in the invasive group and 26.3% in the conservative group experienced a primary outcome event (hazard ratio, 0.94; 95% Confidence Interval [CI], 0.77 to 1.14; p=0.53). On average, patients in the invasive strategy group had 29 additional days free from a primary outcome event over five years compared to those in the conservative group (95% CI, -40 to 98). Interestingly, invasive treatment was associated with a higher rate of cardiovascular death (hazard ratio, 1.11; 95% CI, 0.86 to 1.44) but a lower rate of nonfatal MI (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Additionally, while the invasive approach resulted in fewer strokes (hazard ratio, 0.81; 95% CI, 0.51 to 1.28), it doubled the incidence of TIA (hazard ratio, 2.05; 95% CI, 0.92 to 4.56). Patients treated with invasive therapy were also less likely to undergo further coronary angiography (hazard ratio, 0.20; 95% CI, 0.14 to 0.28) and coronary revascularization (hazard ratio, 0.26; 95% CI, 0.17 to 0.39). The procedure was generally safe, with complications occurring in less than 1% of patients. In conclusion, these findings suggest that invasive treatment is not superior to optimal medical therapy alone in managing older adults with NSTEMI.
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