Early invasive versus initial conservative treatment strategies in octogenarians with UA/NSTEMI

Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years

BACKGROUND

The efficiency of invasive management in older patients (≥75 years) with non-ST-segment elevation myocardial infarction (NSTEMI) remains ambiguous.

OBJECTIVES

To assess the efficiency of invasive management in older patients with NSTEMI based on meta-analysis and trial sequential analysis (TSA).

METHODS

Relevant randomized controlled trials (RCT) and observational studies were included. The primary outcomes were all-cause death, myocardial infarction, stroke, and major bleeding. Pooled odd ratio (OR) and 95% confidence interval (CI) were calculated. P <0.05 was considered statistically significant.

RESULTS

Five RCTs and 22 observational studies with 1017374 patients were included. Based on RCT and TSA results, invasive management was associated with lower risks of myocardial infarction (OR: 0.51; 95% CI: 0.40-0.65; I2=0%), major adverse cardiovascular events (MACE; OR: 0.61; 95% CI: 0.49-0.77; I2=27.0%), and revascularization (OR: 0.29; 95% CI: 0.15-0.55; I2=5.3%) compared with conservative management. Pooling results from RCTs and observational studies with multivariable adjustment showed consistently lower risks of all-cause death (OR: 0.57; 95% CI: 0.50-0.64; I2=86.4%), myocardial infarction (OR: 0.63; 95% CI: 0.56-0.71; I2=0%), stroke (OR: 0.59; 95% CI: 0.51-0.69; I2=0%), and MACE (OR: 0.64; 95% CI: 0.54-0.76; I2=43.4%). The better prognosis associated with invasive management was also observed in real-world scenarios. However, for patients aged ≥85 years, invasive management may increase the risk of major bleeding (OR: 2.68; 95% CI: 1.12-6.42; I2=0%).

CONCLUSIONS

Invasive management was associated with lower risks of myocardial infarction, MACE, and revascularization in older patients with NSTEMI, yet it may increase the risk of major bleeding in patients aged ≥85 years.

Age and Sex Differences and Temporal Trends in the Use of Invasive and Noninvasive Procedures in Patients Hospitalized With Acute Myocardial Infarction

Background

Few studies have examined age and sex differences in the receipt of cardiac diagnostic and interventional procedures in patients hospitalized with acute myocardial infarction and trends in these possible differences during recent years.

Methods and Results

Data from patients hospitalized with a first acute myocardial infarction at the major medical centers in the Worcester, Massachusetts, metropolitan area were utilized for this study. Logistic regression analysis was used to examine age (<55, 55–64, 65–74, and ≥75 years) and sex differences in the receipt of echocardiography, exercise stress testing, coronary angiography, percutaneous coronary interventions, and coronary artery bypass graft surgery, and trends in the use of those procedures during patients' acute hospitalization, between 2005 and 2018, while adjusting for important confounding factors. The study population consisted of 1681 men and 1154 women with an initial acute myocardial infarction who were hospitalized on an approximate biennial basis between 2005 and 2018. A smaller proportion of women underwent cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery, while there were no sex differences in the receipt of echocardiography and exercise stress testing. Patients aged ≥75 years were less likely to undergo cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery, but were more likely to receive echocardiography compared with younger patients. Between 2005 and 2018, the use of echocardiography and coronary artery bypass graft surgery nonsignificantly increased among all age groups and both sexes, while the use of cardiac catheterization and percutaneous coronary intervention increased nonsignificantly faster in women and older patients.

Conclusions

We observed a continued lower receipt of invasive cardiac procedures in women and patients aged ≥75 years with acute myocardial infarction, but age and sex gaps associated with these procedures have narrowed during recent years.

Invasive versus conservative strategy in the very elderly with non-ST-elevation acute coronary syndrome: A meta-analysis of randomized controlled trials

AIM

To investigate the optimal treatment strategy in patients older than 80 years with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

METHODS

All published randomized, placebo-controlled trials (RCTs) reporting on comparisons between invasive and conservative strategies for patients aged 80 years or older with NSTE-ACS were identified. The literature search was performed using PubMed, EMBASE, Cochrane Library, and the ISI Web of Science, from their establishment to July 2021 with no language restriction. The pooled risk ratios (RRs) with 95% confidence intervals (CI) for dichotomous outcomes were calculated.

RESULTS

Three RCTs involving a total of 893 cases met the inclusion criteria. Compared with the conservative group, the invasive strategy could significantly improve the incidence rate of composite endpoint (I²  = 21.9%; RR 0.727, 95% CI 0.619 to 0.855, P < 0.001), recurrent myocardial infarction (MI) (I²  = 0.0%; RR 0.585, 95% CI 0.441 to 0.776, P < 0.001) and revascularization (I²  = 0.0%; RR 0.239, 95% CI 0.126 to 0.455, P < 0.001). However, no benefits were observed on outcomes of all-cause death (I²  = 0.0%; RR 0.888, 95% CI 0.681 to 1.160, P = 0.384), cardiac death (I²  = 0.0%; RR 0.769, 95% CI 0.412 to 1.433, P = 0.408) and stroke (I²  = 0.0%; RR 0.778, 95% CI 0.392 to 1.543, P = 0.473). The major bleeding events were comparable between the two groups (I²  = 0.0%; RR 1.582, 95% CI 0.622 to 4.025, P = 0.336).

CONCLUSIONS

Compared with a conservative strategy, the invasive treatment could reduce the incidence of composite endpoint, recurrent MI, and revascularization in the very elderly with NSTE-ACS. However, no benefits were observed on mortality. Geriatr Gerontol Int 2021; ••: ••-••.

Impact of coronary angioplasty in elderly patients with non-ST-segment elevation myocardial infarction

BACKGROUND

As treatment of coronary artery disease improved over the last years, management of elder patients remained a matter of debate since this age group has been underrepresented in most trials. The study aimed to evaluate a population of patients with ≥ 85 years old with non-ST-segment elevation myocardial infarction (NSTEMI) and compare the prognosis according to coronary revascularization execution.

METHODS

We retrospectively studied 324 patients included in a national multicenter registry between October 2010 and October 2018, who underwent coronary angiography and had at least one stenosis ≥ 50%.

RESULTS

In this population, 73.1% of the patients underwent percutaneous coronary intervention (PCI) and 26.9% of the patients underwent optimized medical treatment (OMT). The OMT group had more past history of diabetes, stroke and dementia. On coronary angiography, the PCI group used more often the femoral artery access and single-vessel lesions were also more common. Three-vessel disease was more common in the OMT group. During hospitalization, there were more major bleeding events and death in the PCI group. During the one-year follow-up, there were no significant differences in all-cause mortality rate.

CONCLUSIONS

Very old patients with NSTEMI submitted to OMT had more comorbidities and more three-vessel disease, factors that could have influenced the therapeutic decision. Patients undergoing PCI had more in-hospital major bleeding events and mortality, with no significant differences after one year.

Clinical Outcomes in Older Patients Undergoing Percutaneous Coronary Intervention for Non-ST-Elevation Acute Coronary Syndromes

BACKGROUND

Distinguishing the subgroup of older, comorbid patients presenting with non-ST-elevation acute coronary syndromes (NSTEACS) who will benefit from percutaneous coronary intervention (PCI) remains challenging. Identifying risk factors for major adverse cardiac or cerebrovascular events (MACCE) post PCI may help define this cohort. The objective of this study was to describe contemporary outcomes of older patients with NSTEACS undergoing PCI and identify pre-procedural risk factors for MACCE.

METHODS

We retrospectively reviewed data for 1,875 patients aged ≥80 years entered in the Victorian Cardiac Outcomes Registry (VCOR) who underwent PCI for NSTEACS between 1 January 2013 and 31 December 2017. MACCE was a composite outcome comprising 30-day mortality, myocardial infarction, stroke, major bleeding, target lesion revascularisation or target vessel revascularisation; in-hospital cardiogenic shock or stent thrombosis; and new requirement for dialysis. Patient demographic data and pre-procedural comorbidities were compared between the groups with and without a MACCE.

RESULTS

The rate of MACCE at 30 days was 8.0% (n=150). Thirty-day (30-day) mortality was 3.0% (n=57). Pre-procedural left ventricular ejection fraction (LVEF)<45% (OR 2.32; 95% CI 1.47-3.68; p<0.001) and eGFR≤30 mL/min/1.73m² or renal replacement therapy (OR 2.10; 95% CI 1.27-3.46; p<0.01) were independent predictors of a MACCE.

CONCLUSIONS

Older patients presenting with NSTEACS who have left ventricular systolic dysfunction or renal impairment are at increased risk of MACCE post PCI. Randomised studies are required to determine if invasive management remains beneficial for these patents compared with medical therapy.

Percutaneous coronary intervention in the very elderly with NSTE-ACS: the randomized 80+ study

Objective: The treatment strategy in the very elderly with NSTE-ACS is debated, as they are often under-represented in clinical trials. The aim of this multicenter randomized controlled trial was to compare invasive and conservative strategies in the very elderly with NSTE-ACS.Methods: We randomly assigned patients ≥ 80 years of age with NSTE-ACS to an invasive strategy with coronary angiography and optimal medical treatment or a conservative strategy with only optimal medical treatment. The primary outcome was the combined endpoint of major adverse cardiac and cerebrovascular events (MACCE). Sample size was powered for a 50% reduction of event rate in MACCE with an invasive strategy. We used intention-to-treat analysis.Results: Altogether, 186 patients were included between 2009 and 2017. The study was terminated prematurely due to slow enrollment. At 12-month follow-up, the primary outcome occurred in 31 (33.3%) of the invasive treatment group and 34 (36.6%) of the conservative treatment group, with a hazard ratio (HR) of 0.90 (95% CI 0.55‒1.46; p = 0.66) for the invasive group relative to the conservative group. The corresponding HR value for urgent revascularization was 0.29 (95% CI 0.10‒0.85; p = 0.02), 0.56 (95% CI 0.27‒1.18; p = 0.13) for myocardial infarction, 0.70 (95% CI 0.31‒1.58; p = 0.40) for all-cause mortality, 1.35 (95% CI 0.23‒7.98; p = 0.74) for stroke, and 1.62 (95% CI 0.67‒3.90; p = 0.28) for recurrent hospitalization for cardiac reasons.Conclusion: In the very elderly with NSTE-ACS, we did not find any significant difference in MACCE between invasive and conservative treatment groups at 12-month follow-up, possibly due to small sample size. ClinicalTrials.gov: NCT02126202.

Temporal Trends and Outcomes of Percutaneous Coronary Interventions in Nonagenarians: A National Perspective

OBJECTIVES

This study sought to assess temporal trends and outcomes of percutaneous coronary intervention (PCI) in nonagenarians.

BACKGROUND

With increasing life expectancy, nonagenarians requiring PCI are increasing even though outcomes data are limited.

METHODS

The National Inpatient Sample was used to identify all hospitalizations for PCI in patients aged ≥90 years from January 1, 2003, to December 31, 2014. The primary outcome was in-hospital mortality.

RESULTS

Nonagenarians (n = 69,271) constituted 0.9% of all PCI hospitalizations, increasing from 0.6% in 2003 to 2004 to 1.4% in 2013 to 2014 (p_trend < 0.001). From 2003-2004 to 2013-2014, the proportion of PCIs performed for ST-segment elevation myocardial infarction (STEMI) (23.1% to 30.9%) and non-ST-segment elevation acute coronary syndromes (49.6% to 52.6%) increased, whereas those for stable ischemic heart disease (SIHD) decreased (27.3% to 16.5%), respectively (p_trend < 0.001 for all). Overall in-hospital mortality after PCI for STEMI, non-ST-segment elevation acute coronary syndromes, and SIHD were 16.4%, 4.2%, and 1.8%, respectively. After multivariable risk adjustment for demographics, comorbidities, and hospital-level characteristics, in-hospital mortality remained unchanged in STEMI (odds ratio: 1.04; 95% confidence interval: 0.98 to 1.11; p_trend = 0.20) and non-ST-segment elevation acute coronary syndromes (odds ratio: 0.99; 95% confidence interval: 0.91 to 1.08; p_trend = 0.82), but increased in SIHD (odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44; p_trend = 0.04) from 2003 to 2004 to 2013 to 2014. The rates of bleeding and vascular complications decreased or remained stable in all 3 subgroups, whereas risk-adjusted incidence of stroke increased in patients with STEMI or SIHD.

CONCLUSIONS

The rate of in-hospital mortality, major bleeding, vascular complications, and stroke after PCI in nonagenarians changed significantly from 2003 to 2014. This study provides a benchmark for discussion of PCI-related risks among physicians, patients, and families.

Long-Term Survival after Invasive or Conservative Strategy in Elderly Patients with non-ST-Elevation Myocardial Infarction: A Prospective Cohort Study

BACKGROUND

The optimal management of elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) is still discussed. We aimed to study short- and long-term survival in NSTEMI patients ≥75 years managed with an invasive or a conservative strategy.

METHODS

NSTEMI patients admitted to Oslo University Hospital Ulleval during 2005-2011 were included consecutively in a prospective registry. Vital status until December 31, 2013, was obtained from the Norwegian Cause of Death Registry. Patients ≥75 years were identified, and 30-day and 7-year survival were analyzed. Logistic- and Cox regression was used to estimate OR and hazard ratio (HR) for death in the invasive versus conservative group, adjusting for registered confounders.

RESULTS

There were 2,064 NSTEMI patients ≥75 years (48.2% women); 1,200 (58.1%) were treated with an invasive strategy, and were younger, more likely to be male and previously revascularized compared to 864 (41.9%) patients treated conservatively (p < 0.0001 for all). Survival at 30-day was 94.9% in the invasive and 76.6% in the conservative group. For 30-day survivors, 7-year survival was 47.4% (95% CI 42.9-51.8) and 11.6% (95% CI 8.3-15.6), respectively. After multivariate adjustment, an invasive strategy was associated with lower long-term risk (adjusted HR [aHR] 0.49 [95% CI 0.41-0.59]). Actual revascularization was associated with lower risk of long-term mortality compared to angiography only (aHRPCI 0.73 [95% CI 0.59-0.90], aHRCABG 0.43 [95% CI 0.28-0.65]).

CONCLUSION

In this real-life cohort of NSTEMI patients ≥75 years, 30-day survival was 95%, and 7-year survival was 47% with an invasive strategy. Revascularized patients had a superior long-term prognosis. With a conservative strategy, short- and long-term survival was lower, probably due to selection bias and unmeasured confounding.

Prognostic impact of percutaneous coronary intervention in octogenarians with non-ST elevation myocardial infarction: A report from SWEDEHEART

AIMS

Percutaneous coronary intervention (PCI) improves outcomes in non-ST elevation acute coronary syndromes (NSTE-ACSs). Octogenarians, however, were underrepresented in the pivotal trials. This study aimed to assess the effect of PCI in patients ≥80 years old.

METHODS AND RESULTS

We used data from the SWEDEHEART registry for all hospital admissions at eight cardiac care centres within Västra Götaland County. Consecutive patients ≥80 years old admitted for NSTE-ACS between January 2000 and December 2011 were included. We performed instrumental variable analysis with propensity score. The primary endpoint was all-cause mortality at 30 days and one year after index hospitalization. During the study period 5200 patients fulfilled the inclusion criteria. In total, 586 (11.2%) patients underwent PCI, the remaining 4613 patients were treated conservatively. Total mortality at 30 days was 19.4% (1007 events) and 39.4% (1876 events) at one year. Thirty-day mortality was 20.7% in conservatively treated patients and 8.5% in the PCI group (adjusted odds ratio 0.34; 95% confidence interval 0.12-0.97, p = 0.044). One-year mortality was 42.1% in the conservatively treated group and 16.3% in the PCI group (adjusted odds ratio 0.97; 95% confidence interval 0.36-2.51, p = 0.847).

CONCLUSIONS

PCI in octogenarians with NSTE-ACS was associated with a lower risk of mortality at 30 days. However, this survival benefit was not sustained during the entire study-period of one-year.

Invasive management of acute coronary syndrome: Interaction with competing risks

BACKGROUND

The aim of this study was to characterise the interaction between ACS- and non-ACS-risk on the benefits of invasive management in patients presenting with acute coronary syndrome (ACS).

METHODS

Consecutive patients admitted to a tertiary hospital's Cardiac Care Unit in the months of July-December, 2003-2011 with troponin elevation (>30 ng/L) were included. "ACS-specific-risk" was estimated using the GRACE score and "non-ACS-risk" was estimated using the Charlson-Comorbidity-Index (CCI). Inverse-probability-of-treatment weighting was used to adjust for baseline differences between patients who did or did not receive invasive management. A multivariable flexible parametric model was used to characterise the time-varying hazard.

RESULTS

In total, 3057 patients were included with a median follow-up of 9.0 years. Based on CCI, 1783 patients were classified as 'low-non-ACS risk' (CCI ≤ 1; invasive management 81%; 12-month mortality 5%), 820 as 'medium-non-ACS risk' (CCI 2-3; invasive management 68%; 12-month mortality 13%), and 468 as 'high-non-ACS risk' (CCI ≥ 4; invasive management 47%; 12-month mortality 29%). After adjustment, invasive management was associated with a significant reduction in one-year overall-mortality in the 'low-risk' and 'medium-risk' groups (HR = 0.38, 95%CI:0.26-0.56; HR = 0.46, 95%CI:0.32-0.67); but not in the 'high-risk' group (HR = 1.02, 95%CI:0.67-1.56). The absolute benefit of invasive management was greatest with higher baseline ACS-risk, with a non-linear interaction between ACS- and non-ACS-risk.

CONCLUSIONS

There is a complex interaction between ACS- and non-ACS-risk on the benefit of invasive management. These results highlight the need to develop robust methods to objectively quantify risk attributable to non-ACS comorbidities in order to make informed decisions regarding the use of invasive management in individuals with numerous comorbidities.

Early Invasive Versus Initial Conservative Strategies for Women with Non-ST-Elevation Acute Coronary Syndromes: A Nationwide Analysis

BACKGROUND

Studies conducted largely in men have shown improved outcomes with an early invasive strategy with non-ST-elevation acute coronary syndrome. In contrast, data have been less conclusive in women, with some trials demonstrating potential harm. This study aims to assess whether an early invasive strategy in women is associated with better outcomes in real-world data.

METHODS

Women admitted with a primary diagnosis of non-ST-elevation myocardial infarction or unstable angina were identified from the National Inpatient Sample years 2012 and 2013. The incidence of in-hospital mortality in women with non-ST-elevation acute coronary syndrome undergoing an early invasive strategy versus an initial conservative strategy was compared using a propensity score-matched analysis.

RESULTS

Among 372,080 women with non-ST-elevation acute coronary syndrome, 153,680 (41.3%) were managed with an early invasive strategy and 218,400 (58.7%) were managed with an initial conservative strategy. Propensity score-matched 19,965 women were treated with an early invasive strategy, and 20,009 women were treated with an initial conservative strategy. The risk of in-hospital mortality was lower with an early invasive strategy (2.1% vs 3.8%; odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.62). This benefit was noted in women presenting with non-ST-segment elevation myocardial infarction (OR, 0.52; 95% CI, 0.46-0.58) and was not observed in women with unstable angina (OR, 5.14; 95% CI, 0.47-56.9), P_interaction = .06. A propensity-adjusted analysis yielded similar results (OR, 0.51; 95% CI, 0.45-0.57).

CONCLUSIONS

In this large contemporary observational analysis of women with non-ST-elevation acute coronary syndrome, an early invasive strategy was associated with lower in-hospital mortality. This benefit was observed in women presenting with non-ST-elevation myocardial infarction but not with unstable angina. These findings provide evidence supporting the guideline recommendations for an early invasive strategy in women with non-ST-elevation acute coronary syndrome and high-risk features (eg, troponin positive).

Early Invasive Versus Initially Conservative Strategy in Elderly Patients Older Than 75 Years with Non-ST-Elevation Acute Coronary Syndrome: A Meta-Analysis

BACKGROUND

Fear of complications related to the procedure and unclear benefits in elderly patients are common reasons for invasive angiography being withheld.

METHODS

We searched PubMed and Embase from inception until February 2016 for studies that enrolled individuals older than 75 years with non-ST-elevation acute coronary syndrome (NSTE-ACS) and allocated patients to either an invasive or conservative strategy.

RESULTS

Thirteen studies (four randomised controlled trials (RCTs) and nine observational studies) enrolling 832,007 elderly NSTE-ACS patients were analysed. Compared with the conservative treatment, the early invasive approach does significantly reduce the risk of death at follow-up from 6 months to 5 years (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.59-0.73, p<0.001); the definite benefit was mainly observed in observational studies (RR 0.63, 95% CI 0.57-0.70, p<0.001), and the risk of death also showed a strong trend toward reduction with invasive approach (RR 0.82, 95% CI 0.64-1.05, p=0.119) in RCTs. For the outcome of bleeding complications, there was a higher risk of any bleeding occurring in-hospital (RR 2.51, 95% CI 1.53-4.11, p<0.001) in patients treated with invasive strategy than those treated with conservative strategy. However, no difference of in-hospital major bleeding (RR 1.78, 95% CI 0.31-10.13, p=0.514) was observed between the two strategies.

CONCLUSION

Elderly patients with NSTE-ACS might benefit from an early invasive strategy but with increasing risk of any bleeding complications. More RCTs are needed to assess early invasive strategies in the elderly.

Early Invasive Strategy and In-Hospital Survival Among Diabetics With Non-ST-Elevation Acute Coronary Syndromes: A Contemporary National Insight

Background

There are limited data on the merits of an early invasive strategy in diabetics with non‐ST‐elevation acute coronary syndrome, with unclear influence of this strategy on survival. The aim of this study was to evaluate the in‐hospital survival of diabetics with non‐ST‐elevation acute coronary syndrome treated with an early invasive strategy compared with an initial conservative strategy.

Methods and Results

The National Inpatient Sample database, years 2012–2013, was queried for diabetics with a primary diagnosis of non‐ST‐elevation acute coronary syndrome defined as either non‐ST‐elevation myocardial infarction or unstable angina (unstable angina). An early invasive strategy was defined as coronary angiography±revascularization within 48 hours of admission. Propensity scores were used to assemble a cohort managed with either an early invasive or initial conservative strategy balanced on >50 baseline characteristics and hospital presentations. Incidence of in‐hospital mortality was compared in both groups. In a cohort of 363 500 diabetics with non‐ST‐elevation acute coronary syndrome, 164 740 (45.3%) were treated with an early invasive strategy. Propensity scoring matched 21 681 diabetics in both arms. Incidence of in‐hospital mortality was lower with an early invasive strategy in both the unadjusted (2.0% vs 4.8%; odds ratio [OR], 0.41; 95% CI, 0.39–0.42; P<0.0001) and propensity‐matched models (2.2% vs 3.8%; OR, 0.57; 95% CI, 0.50–0.63; P<0.0001). The benefit was observed across various subgroups, except for patients with unstable angina (P_interaction=0.02).

Conclusions

An early invasive strategy may be associated with a lower incidence of in‐hospital mortality in patients with diabetes. The benefit of this strategy appears to be superior in patients presenting with non‐ST‐elevation myocardial infarction compared with unstable angina.

Randomized comparison between the invasive and conservative strategies in comorbid elderly patients with non-ST elevation myocardial infarction

BACKGROUND

Comorbid elderly patients with non-ST-elevation myocardial infarction (non-STEMI) are underrepresented in randomized trials and undergo fewer cardiac catheterizations according to registries. Our aim was to compare the conservative and invasive strategies in these patients.

METHODS

Randomized multicenter study, including 106 patients (January 2012-March 2014) with non-STEMI, over 70years and with comorbidities defined by at least two of the following: peripheral artery disease, cerebral vascular disease, dementia, chronic pulmonary disease, chronic renal failure or anemia. Patients were randomized to invasive (routine coronary angiogram, n=52) or conservative (coronary angiogram only if recurrent ischemia or heart failure, n=54) strategy. Medical treatment was identical. The main endpoint was the composite of all-cause mortality, reinfarction and readmission for cardiac cause (postdischarge revascularization or heart failure), at long-term (2.5-year follow-up). Analysis of cumulative event rate (incidence rate ratio=IRR) and time to first event (hazard ratio=HR), were performed.

RESULTS

Cardiac catheterization/revascularization rates were 100%/58% in the invasive versus 20%/9% in the conservative arm. There were no differences between groups in the main endpoint (invasive vs conservative: IRR=0.946, 95% CI 0.466-1.918, p=0.877) at long-term. The invasive strategy, however, tended to improve 3-month outcomes in terms of mortality (HR=0.348, 95% CI 0.122-0.991, p=0.048), and of mortality or ischemic events (reinfarction or postdischarge revascularization) (HR=0.432, 95% CI 0.190-0.984, p=0.046). This benefit declined during follow-up.

CONCLUSIONS

Invasive management did not modify long-term outcome in comorbid elderly patients with non-STEMI. The finding of a tendency towards an improvement in the short-term needs confirmation in larger studies (clinicaltrials.govNCT1645943).

Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial

BACKGROUND

Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris are frequent causes of hospital admission in the elderly. However, clinical trials targeting this population are scarce, and these patients are less likely to receive treatment according to guidelines. We aimed to investigate whether this population would benefit from an early invasive strategy versus a conservative strategy.

METHODS

In this open-label randomised controlled multicentre trial, patients aged 80 years or older with NSTEMI or unstable angina admitted to 16 hospitals in the South-East Health Region of Norway were randomly assigned to an invasive strategy (including early coronary angiography with immediate assessment for percutaneous coronary intervention, coronary artery bypass graft, and optimum medical treatment) or to a conservative strategy (optimum medical treatment alone). A permuted block randomisation was generated by the Centre for Biostatistics and Epidemiology with stratification on the inclusion hospitals in opaque concealed envelopes, and sealed envelopes with consecutive inclusion numbers were made. The primary outcome was a composite of myocardial infarction, need for urgent revascularisation, stroke, and death and was assessed between Dec 10, 2010, and Nov 18, 2014. An intention-to-treat analysis was used. This study is registered with ClinicalTrials.gov, number NCT01255540.

FINDINGS

During a median follow-up of 1·53 years of participants recruited between Dec 10, 2010, and Feb 21, 2014, the primary outcome occurred in 93 (40·6%) of 229 patients assigned to the invasive group and 140 (61·4%) of 228 patients assigned to the conservative group (hazard ratio [HR] 0·53 [95% CI 0·41-0·69], p=0·0001). Five patients dropped out of the invasive group and one from the conservative group. HRs for the four components of the primary composite endpoint were 0·52 (0·35-0·76; p=0·0010) for myocardial infarction, 0·19 (0·07-0·52; p=0·0010) for the need for urgent revascularisation, 0·60 (0·25-1·46; p=0·2650) for stroke, and 0·89 (0·62-1·28; p=0·5340) for death from any cause. The invasive group had four (1·7%) major and 23 (10·0%) minor bleeding complications whereas the conservative group had four (1·8%) major and 16 (7·0%) minor bleeding complications.

INTERPRETATION

In patients aged 80 years or more with NSTEMI or unstable angina, an invasive strategy is superior to a conservative strategy in the reduction of composite events. Efficacy of the invasive strategy was diluted with increasing age (after adjustment for creatinine and effect modification). The two strategies did not differ in terms of bleeding complications.

FUNDING

Norwegian Health Association (ExtraStiftelsen) and Inger and John Fredriksen Heart Foundation.

An overview of PCI in the very elderly

Cardiovascular disease, and in particular ischemic heart disease (IHD), is a major cause of morbidity and mortality in the very elderly (> 80 years) worldwide. These patients represent a rapidly growing cohort presenting for percutaneous coronary intervention (PCI), now constituting more than one in five patients treated with PCI in real-world practice. Furthermore, they often have greater ischemic burden than their younger counterparts, suggesting that they have greater scope of benefit from coronary revascularization therapy. Despite this, the very elderly are frequently under-represented in clinical revascularization trials and historically there has been a degree of physician reluctance in referring them for PCI procedures, with perceptions of disappointing outcomes, low success and high complication rates. Several issues have contributed to this, including the tendency for older patients with IHD to present late, with atypical symptoms or non-diagnostic ECGs, and reservations regarding their procedural risk-to-benefit ratio, due to shorter life expectancy, presence of comorbidities and increased bleeding risk from antiplatelet and anticoagulation medications. However, advances in PCI technology and techniques over the past decade have led to better outcomes and lower risk of complications and the existing body of evidence now indicates that the very elderly actually derive more relative benefit from PCI than younger populations. Importantly, this applies to all PCI settings: elective, urgent and emergency. This review discusses the role of PCI in the very elderly presenting with chronic stable IHD, non ST-elevation acute coronary syndrome, and ST-elevation myocardial infarction. It also addresses the clinical challenges met when considering PCI in this cohort and the ongoing need for research and development to further improve outcomes in these challenging patients.

Non-ST-elevation myocardial infarction in the United States: contemporary trends in incidence, utilization of the early invasive strategy, and in-hospital outcomes

Background

There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non‐ST‐elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in‐hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in‐hospital outcomes of NSTEMI in the United States.

Methods and Results

We analyzed the 2002–2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age‐, sex‐, and race/ethnicity‐stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age‐, sex‐, and race/ethnicity‐stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (P_trend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (P_trend<0.001). Risk‐adjusted in‐hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978).

Conclusions

There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in‐hospital mortality and length of stay.