The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute
Richard G Bach1, Christopher P Cannon, William S Weintraub
1Cardiovascular Division, Washington University Medical Center, St. Louis, Missouri 63110, USA. rbach@im.wustl.edu
Insights
An early invasive strategy significantly reduces death or myocardial infarction (MI) in elderly patients with unstable angina. While bleeding risk increases in those over 75, invasive management improves ischemic outcomes.
Area of Science:
- Cardiology
- Geriatric Medicine
- Clinical Trials
Background:
- Increasing age is a significant risk factor for adverse outcomes in acute coronary syndromes.
- Elderly patients with acute coronary syndromes are often managed conservatively, potentially missing optimal treatment benefits.
Purpose of the Study:
- To evaluate the outcomes of early invasive versus conservative management strategies in elderly patients with unstable angina and non-ST-segment elevation myocardial infarction (MI).
- To compare the effectiveness and safety of different management strategies based on patient age.
Main Methods:
- A randomized controlled trial involving 2220 patients with unstable angina or non-ST-segment elevation MI.
- Patients were assigned to either an early invasive strategy (including early angiography) or a conservative strategy (medical therapy and predischarge exercise testing).
- Outcomes assessed included mortality, nonfatal MI, rehospitalization, stroke, and bleeding complications at 30 days and 6 months.
Main Results:
- Elderly patients (≥65 years) managed with an early invasive strategy showed a significant reduction in death or MI at 6 months compared to conservative management (8.8% vs. 13.6%).
- Patients over 75 years experienced an even greater benefit with the invasive strategy, with a 56% relative reduction in death or MI.
- Outcomes were similar between strategies in patients younger than 65.
- Major bleeding rates were higher in patients over 75 managed invasively (16.6% vs. 6.5%).
Conclusions:
- A routine early invasive strategy significantly improves ischemic outcomes for elderly patients diagnosed with unstable angina and non-ST-segment elevation MI.
- Despite a higher risk of major bleeding in the very elderly (over 75), the benefits of an invasive approach in preventing ischemic events outweigh the risks.
- Generalizability to elderly patients with excluded comorbid conditions from this trial requires further investigation.
Background:
Although increasing age is an important risk factor for adverse outcome among patients with acute coronary syndromes, elderly patients are more often managed conservatively.
Objective:
To examine outcome according to age and management strategy for patients with unstable angina and non-ST-segment elevation myocardial infarction (MI).
Design:
Randomized, controlled trial conducted from December 1997 to June 2000.
Setting:
169 community and tertiary care hospitals in 9 countries.
Patients:
2220 patients hospitalized with unstable angina and non-ST-segment elevation MI who were randomly assigned to an early invasive or conservative management strategy.
Interventions:
Medical therapy and coronary angiography at 4 to 48 hours versus medical therapy and predischarge exercise testing.
Measurements:
Rates of 30-day and 6-month mortality, nonfatal MI, rehospitalization, stroke, and hemorrhagic complications.
Results:
Among patients 65 years of age and older, the early invasive strategy compared with the conservative strategy yielded an absolute reduction of 4.8 percentage points (8.8% vs. 13.6%; P = 0.018) and a relative reduction of 39% in death or MI at 6 months. Outcomes of the 2 strategies were similar, however, among patients younger than 65 years of age (6.1% vs. 6.5%; P > 0.2). Among patients older than 75 years of age, the early invasive strategy conferred an absolute reduction of 10.8 percentage points (10.8% vs. 21.6%; P = 0.016) and a relative reduction of 56% in death or MI at 6 months. The additional cost per death or MI prevented with the early invasive strategy was lower for elderly patients, but major bleeding rates were higher with this strategy in patients older than 75 years of age (16.6% vs. 6.5%; P = 0.009).
Limitations:
Because this study involved patients in the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction (TACTICS-TIMI) 18 trial, its generalizability to elderly patients with excluded comorbid conditions is unknown.
Conclusion:
Despite an increased risk for major bleeding in patients older than 75 years of age, a routine early invasive strategy can significantly improve ischemic outcomes in elderly patients with unstable angina and non-ST-segment elevation MI.
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