Invasive versus conservative management in patients aged ≥85 years presenting with non-ST-elevation myocardial...

Area of Science:

• Cardiology
• Geriatric Medicine
• Interventional Cardiology

Background:

• Current guidelines recommend early coronary angiography (CA) for non-ST-elevation myocardial infarction (NSTEMI) regardless of age.
• Elderly patients (≥85 years) are often undertreated due to perceived high risks and comorbidities.
• The survival benefit of invasive strategies in very elderly NSTEMI patients remains unclear due to trial exclusions.

Purpose of the Study:

• To evaluate the association between invasive management (including CA) and long-term mortality in patients aged ≥85 years with NSTEMI.
• To assess the safety of invasive management in this population, focusing on in-hospital bleeding and stroke.
• To determine if an invasive approach improves survival in very elderly NSTEMI patients.

Main Methods:

• Retrospective cohort study of consecutive patients aged ≥85 years presenting with NSTEMI (2008-2018).
• Patients were stratified into invasive management (with CA and revascularization) versus conservative management groups.
• Cox regression analysis adjusted for age, functional status, cognition, and cardiovascular risk factors.

Main Results:

• Out of 1052 elderly NSTEMI patients, only 9.4% underwent CA, typically those who were younger, male, and functionally independent.
• Invasive management was the strongest predictor of survival (HR 0.47; P=0.01) after adjustment.
• A trend towards increased in-hospital bleeding was observed (6.1% vs 2.6%; P=0.054), with no significant difference in stroke rates.

Conclusions:

• Invasive management in very elderly NSTEMI patients (≥85 years) is associated with improved long-term survival.
• This approach did not significantly increase the risk of stroke and showed only a trend towards higher bleeding.
• A randomized controlled trial is needed to confirm the efficacy and safety of invasive strategies in this specific patient group.