Angiographic Characteristics of Older Patients with Non-ST Elevation Myocardial Infarction Undergoing Invasive Strategy
Graziella PompeiFrancesca RubinoKenny JenkinsHanna RatcovichDavid AustinShrilla BanerjeeGill Louise BuchananShahid JunejoAbdul NasserNehal HusseinJolanta SobolewskaTimothy WilliamsStuart HoodAwsan NomanAkhlaque UddinManas SinhaRobert J. ButlerJohn IrvingRobert F. StoreyDavid E. NewbyKeith A.A. FoxStuart PocockVijay Kunadian
Key result
Invasive evaluation reveals obstructive CAD in ~77% of older NSTEMI patients, with untreated lesions showing severe calcification.
- n=1,518
Figures
Why the study?
To describe the angiographic characteristics of older NSTEMI patients randomized to the invasive strategy arm in the SENIOR-RITA trial.
Study Design
Type
Observational (n=1,518)
Blinding
Open-label
Randomization
1:1
Multicenter
Yes
Structured PICO
P
Population
1,518 older adults (aged ≥75 years) with NSTEMI, randomized to an invasive or conservative strategy, with 667 in the invasive arm undergoing detailed quantitative coronary angiography analysis.
I
Intervention
Invasive strategy consisting of coronary angiography with revascularization if appropriate (PCI or CABG) plus optimal medical therapy (aspirin, P2Y12 inhibitor, beta-blocker, statin, ACEi/ARB).
C
Comparator
Conservative management with optimal medical therapy alone.
O
Outcome
Angiographic characteristics of patients randomized to the invasive arm, analyzed using quantitative coronary angiography (QCA).surrogate
Limitations
- Revascularization data only include details on percutaneous treatment, excluding those who received CABG post-randomization
- Non-analysable angiograms due to missing acquisitions resulting from challenging arterial access or unreadable discs
- Lesion length analysis did not take into account chronic total occlusions
- Outcomes are not reported according to the complexity of the coronary pathology
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Our hypothesis was that an invasive strategy on top of optimal medical therapy vs. a conservative strategy of optimal medical therapy alone would be superior in terms of reducing the combined risk of cardiovascular death or non-fatal MI in patients aged ≥75 years admitted with a NSTEMI. In a broad inclusive trial population, which represents the older patients we see in our daily clinical practice, we did not see a reduction in the combined risk of cardiovascular death or non-fatal MI, but we did see a reduction in recurrent non-fatal MIs and the need for subsequent revascularisation procedures.”
“The most notable finding in SENIOR-RITA was that approximately 76% of patients in the conservative arm did not have a coronary angiogram and 86% were not revascularized. Yet, the rate of CV death and MI were similar during 4 years of follow-up. This observation is nearly identical to the findings in chronic stable disease, seen in the ISCHEMIA trial.”
Implication
High lesion complexity may limit PCI in older NSTEMI patients; leaves open whether anatomy-tailored selection improves outcomes in future trials.
Abstract
Background In the SENIOR-RITA trial, among older adults with non-ST-elevation myocardial infarction (NSTEMI), an invasive strategy did not reduce the composite outcome of cardiovascular death or non-fatal myocardial infarction compared with a conservative strategy over a median follow-up of 4.1 years. Objectives To describe the angiographic characteristics of patients randomized to the invasive arm. Methods SENIOR-RITA was a prospective, multicentre, randomized controlled trial recruiting NSTEMI patients aged ≥75 years. From November 2016 to March 2023, 1518 patients from 48 UK sites were randomized 1:1 to an invasive or conservative strategy. Procedural data were collected, and angiographic data were analysed using quantitative coronary angiography (QCA) at Newcastle University angiographic core laboratory using QAngio® XA Medis. Results Of 680 patients undergoing angiography, QCA analysis was performed in 667 participants. Obstructive coronary artery disease was found in 76.8%, and 13% had prior coronary surgical revascularization. A total of 1173 lesions were identified. Most lesions (29.5%) were classified as type B2 according to the ACC/AHA classification. Lesions in patients not receiving percutaneous coronary intervention (PCI) were angiographically more complex than those treated with PCI, with higher prevalence of type C lesions, bifurcation, ostial lesions, and presence of collaterals. Overall, 330 patients (49.5%) underwent PCI, which was successful in 96.5% with minimal complications. Conclusions The SENIOR-RITA angiography sub-study is the largest subgroup analysis to date in older NSTEMI adults providing important insights into the angiographic characteristics and emphasising the importance of a holistic patient-centred care for older adults.
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Cite This Study
Pompei et al. (2026) conducted an observational in Non-ST-elevation myocardial infarction (NSTEMI) (n=1,518). Invasive strategy (coronary angiography and revascularization if appropriate) vs. Conservative strategy (optimal medical therapy alone) was evaluated on Obstructive coronary artery disease (>50% diameter stenosis). In older adults with NSTEMI undergoing an invasive strategy, 76.8% had obstructive coronary artery disease, and those not receiving PCI had more complex, severely calcified lesions.