Randomized comparison between the invasive and conservative strategies in comorbid elderly patients with non-ST
Juan Sanchis1, Eduardo Núñez1, José Antonio Barrabés2
1Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain.
Insights
Invasive management for elderly patients with non-ST-elevation myocardial infarction (non-STEMI) did not improve long-term outcomes. However, early invasive strategies showed a trend towards better short-term mortality and ischemic event rates.
Area of Science:
- Cardiology
- Geriatric Medicine
- Clinical Trials
Background:
- Elderly patients with non-ST-elevation myocardial infarction (non-STEMI) and comorbidities are often underrepresented in clinical trials.
- Registry data suggest these patients receive fewer cardiac catheterizations compared to younger populations.
Purpose of the Study:
- To compare the effectiveness of conservative versus invasive management strategies in comorbid elderly patients diagnosed with non-STEMI.
- To evaluate long-term composite endpoints including mortality, reinfarction, and cardiac readmissions.
Main Methods:
- A randomized multicenter study involving 106 patients over 70 years old with non-STEMI and significant comorbidities.
- Patients were randomized to either an invasive strategy (routine coronary angiogram) or a conservative strategy (angiogram only if recurrent ischemia or heart failure).
- The primary endpoint was a composite of all-cause mortality, reinfarction, and cardiac readmission assessed over a 2.5-year follow-up period.
Main Results:
- Routine cardiac catheterization and revascularization rates were significantly higher in the invasive group (100%/58%) compared to the conservative group (20%/9%).
- No significant difference was observed in the long-term composite endpoint between the invasive and conservative strategies (IRR=0.946, p=0.877).
- The invasive strategy showed a trend towards improved 3-month outcomes, including reduced mortality (HR=0.348, p=0.048) and fewer ischemic events (HR=0.432, p=0.046), though this benefit diminished over time.
Conclusions:
- Invasive management strategies do not alter long-term outcomes in elderly, comorbid patients with non-STEMI.
- A potential short-term benefit of invasive management warrants further investigation in larger clinical studies to confirm findings.
- Future research should focus on identifying specific subgroups who may benefit from early invasive approaches.
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).
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