Publications of the Week: Invasive vs conservative treatment strategies in elderly patients with NSTEMI

Background: There is uncertainty about the safety of adopting a conservative strategy of the best available medical therapy alone versus the potential benefits of a more aggressive strategy of the best medical therapy and, if needed, revascularization in elderly patients (aged ≥75 years) with non–ST-segment elevation myocardial infarction (NSTEMI).

Methods: This was a randomized controlled trial of patients with NSTEMI aged ≥75 years. Patients were allocated to receive a conservative strategy of the best available medical therapy or to receive a more aggressive invasive strategy of the best medical therapy plus coronary angiography and, as appropriate, coronary revascularization. Patients with frailty or a high burden of comorbidities were included. The primary study outcome was a composite of death from cardiovascular causes or nonfatal myocardial infarction (MI).

Results: There were 1518 patients randomized: 765 to the conservative-strategy group and 753 to the invasive-strategy group. The mean age was 82 years (55% men, 32% frail). Over 80% of patients in each group were receiving dual antiplatelet therapy and >10% were receiving triple therapy (dual antiplatelet therapy plus an anticoagulant). In the conservative-strategy group, 24% of patients required a coronary angiography during the follow-up, among whom about half needed revascularization. In the invasive strategy group, ~50% had coronary revascularization.

During a median follow-up of 4.1 years, a primary-outcome event occurred in 25.6% (193) of patients in the invasive-strategy group and 26.3% (201) of patients in the conservative-strategy group (hazard ratio [HR], 0.94; 95% CI, 0.77-1.14). Cardiovascular death occurred in 15.8% of patients in the invasive-strategy group and in 14.2% of patients in the conservative-strategy group (HR, 1.11; 95% CI, 0.86-1.44). Nonfatal MI occurred in 11.7% of individuals in the invasive-strategy group and 15.0% in the conservative-strategy group (HR, 0.75; 95% CI, 0.57-0.99). Procedure-related complications occurred in <1% of patients.

Conclusions: In older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal MI than a conservative strategy over a median follow-up of 4.1 years.

McMaster editors’ commentary: This is a landmark study. Alongside other similar trials, it may change practices relating to NSTEMI management in the elderly. Whereas a more aggressive strategy may be appropriate for some patients, for example those with recurrent symptoms and/or hospitalized, opting for the best available medical treatment alone does not appear to place patients at an increased risk for cardiovascular death. Patients’ values and preference may be pivotal in clinical decision making.