Values & turf
A values / turf tradeoff — more data alone will not resolve it.
Resolves via: Shared decision-making + role clarity
Thousands of very old patients a year either get wheeled to the cath lab out of habit, or get told medicines are enough — and for the frailest, the wrong default may shorten life rather than extend it.
Active since Sep 2024
The debate
2 clinicians quoted on the record
Angiography in older patients turned out to be safe with almost no procedural complications, it cut repeat heart attacks, and judging who is 'too frail' by eyeball is exactly how older patients have been undertreated for decades.
“To me it amounts to discrimination against the elderly! Now that I am old, I would want an early invasive strategy if I (god forbids) get NSTEMI!”
The trial showed no survival benefit, and at the highest levels of frailty the signal tipped toward harm — so in a patient with limited reserve and dementia, an invasive workup buys procedures and hospital days instead of better years.
“Patients who are severely frail can be treated with medical therapy alone.”
Where the field stands
Common ground
Nobody thinks age alone should decide, and everyone accepts that the procedure itself is low-risk in older patients.
The crux
Whether severe frailty should flip the default from angiography to medicines, or whether that call is too unreliable to act on.
Still unknown
A trial that enrolls frail and cognitively impaired patients on purpose and reports function and quality of life, not just death and reinfarction.
Where do you land?
No votes yet — the measured split appears at 10.
Where the evidence stands
SENIOR-RITA (n=1518, mean age 82) found no reduction in CV death or nonfatal MI with a routine invasive strategy versus conservative care over 4.1 years. Nonfatal MI and later revascularization fell; procedural complications were <1%. Guidelines still generally favor an invasive approach in NSTEMI irrespective of age.
What's settled
4What's still open
4How this gets settled
Who could settle it
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Who could fund or run it
Institutions that could fund, run, or adopt
Sources & verification
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