Revascularisation compared with initial medical therapy for non-ST-elevation acute coronary syndromes in the elderly:
Sonali R Gnanenthiran1,2, Leonard Kritharides1,2, Mario D'Souza2
1Cardiology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.
Insights
Routine invasive therapy for elderly patients with non-ST-elevation acute coronary syndromes (NSTEACS) reduces mortality, myocardial infarction, and stroke. However, it may increase major bleeding risk, necessitating further research.
Area of Science:
- Cardiology
- Geriatric Medicine
- Interventional Cardiology
Background:
- Non-ST-elevation acute coronary syndromes (NSTEACS) in older populations present a complex clinical challenge.
- The optimal management strategy, balancing revascularization against medical therapy, remains debated due to inconclusive trial evidence.
Purpose of the Study:
- To compare the efficacy and safety of routine invasive therapy versus initial medical management in elderly patients (≥75 years) with NSTEACS.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies.
- Searched MEDLINE, EMBASE, and Cochrane Controlled Trial Register for relevant studies.
- Endpoints included mortality, myocardial infarction (MI), revascularization, rehospitalization, stroke, and major bleeding.
Main Results:
- Routine invasive therapy significantly reduced mortality (OR 0.67), MI (OR 0.56), and stroke (OR 0.53) across all included studies.
- RCT-specific analyses confirmed reductions in MI (OR 0.51) and revascularization (OR 0.27), with a trend towards reduced mortality (OR 0.84).
- Increased major bleeding risk (OR 2.19) was observed, though differences were less apparent in recent studies.
Conclusions:
- Routine invasive therapy offers benefits in reducing MI and repeat revascularization, with potential mortality benefits for elderly NSTEACS patients.
- The increased risk of major bleeding necessitates careful consideration and further research.
- Additional RCTs are crucial to definitively ascertain the impact on mortality and contemporary bleeding risks.
Objective:
Whether revascularisation is superior to medical therapy in older populations presenting with non-ST-elevation acute coronary syndromes (NSTEACS) remains contentious, with inconclusive evidence from randomised trials. We aimed to compare routine invasive therapy with initial medical management in the elderly presenting with NSTEACS.
Methods:
MEDLINE, EMBASE and Cochrane Controlled Trial Register were searched for studies comparing routine invasive therapy with initial medical management in patients ≥75 years old presenting with NSTEACS. Endpoints included long-term mortality, myocardial infarction (MI), revascularisation, rehospitalisation, stroke and major bleeding reported as ORs.
Results:
Four randomised trials and three observational studies met inclusion criteria, enrolling a total of 20 540 patients followed up from 6 months to 5 years. Routine invasive therapy reduced mortality (OR 0.67, CI 0.61 to 0.74), MI (OR 0.56, CI 0.45 to 0.70) and stroke (OR 0.53, CI 0.30 to 0.95). Analyses restricted to randomised controlled trials (RCTs) confirmed a reduction in MI (OR 0.51, CI 0.40 to 0.66), revascularisation (OR 0.27, CI 0.13 to 0.56) and a trend to reduced mortality (OR 0.84, CI 0.66 to 1.06) at the expense of major bleeding (OR 2.19, CI 1.12 to 4.28). Differences in major bleeding were unapparent in more recent studies.
Conclusion:
Routine invasive therapy reduces MI and repeat revascularisation and may reduce mortality at the expense of major bleeding in elderly patients with NSTEACS. Our findings highlight the need for further RCTs to better determine the effect on mortality and contemporary bleeding risk.
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