Effect of Routine Invasive vs Conservative Strategy in Older Adults With Frailty and Non-ST-Segment Elevation Acute...

Area of Science:

• Cardiology
• Geriatric Medicine
• Clinical Trials

Background:

• Frail older adults with non-ST-segment elevation acute myocardial infarction (NSTEMI) represent a vulnerable population.
• Optimal management strategies for NSTEMI in this demographic remain unclear, with no prior randomized clinical trials directly comparing invasive and conservative approaches.

Purpose of the Study:

• To compare the 1-year outcomes of routine invasive versus conservative management strategies in frail older patients diagnosed with NSTEMI.

Main Methods:

• A multicenter randomized clinical trial involving 167 frail patients (age ≥70 years, Clinical Frailty Scale score ≥4) with NSTEMI.
• Patients were randomized to either a routine invasive strategy (coronary angiography and revascularization) or a conservative strategy (medical treatment with angiography for recurrent ischemia).
• The primary endpoint was days alive and out of hospital (DAOH) at 1 year; a coprimary endpoint included cardiac death, reinfarction, or postdischarge revascularization.

Main Results:

• The study was stopped early due to the COVID-19 pandemic.
• No statistically significant difference was observed in DAOH between the conservative (312 days) and invasive (284 days) groups (P=.12).
• There were no significant differences in all-cause mortality, readmissions, or ischemic cardiac events between the two management strategies.

Conclusions:

• In frail older patients with NSTEMI, a routine invasive strategy did not demonstrate a benefit in terms of days alive and out of hospital at 1 year compared to a conservative approach.
• Medical management with watchful observation appears to be a recommended strategy for this specific patient population.