Key result
An invasive strategy in NSTEMI patients ≥75 years was associated with a lower long-term risk of death compared to a conservative strategy (adjusted HR 0.49; 95% CI 0.41-0.59).
Why the study?
The optimal management of elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) remains debated.
Does an invasive strategy improve short- and long-term survival in NSTEMI patients ≥75 years compared to a conservative strategy?
Cohort (n=2,064)
No
Does an invasive strategy improve short- and long-term survival in NSTEMI patients ≥75 years compared to a conservative strategy?
Hazard Ratio: 0.49 (95% CI 0.41–0.59)
Absolute Event Rate: 47.4% vs 11.6%
In a real-world cohort of elderly NSTEMI patients, an invasive strategy was associated with significantly better short- and long-term survival compared to a conservative strategy, though selection bias may contribute to this finding.
Invasive strategy was associated with better survival in elderly NSTEMI; leaves open whether benefit reflects selection bias, warranting randomized confirmation.
BACKGROUND: The optimal management of elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) is still discussed. We aimed to study short- and long-term survival in NSTEMI patients ≥75 years managed with an invasive or a conservative strategy. METHODS: NSTEMI patients admitted to Oslo University Hospital Ulleval during 2005-2011 were included consecutively in a prospective registry. Vital status until December 31, 2013, was obtained from the Norwegian Cause of Death Registry. Patients ≥75 years were identified, and 30-day and 7-year survival were analyzed. Logistic- and Cox regression was used to estimate OR and hazard ratio (HR) for death in the invasive versus conservative group, adjusting for registered confounders. RESULTS: There were 2,064 NSTEMI patients ≥75 years (48.2% women); 1,200 (58.1%) were treated with an invasive strategy, and were younger, more likely to be male and previously revascularized compared to 864 (41.9%) patients treated conservatively (p < 0.0001 for all). Survival at 30-day was 94.9% in the invasive and 76.6% in the conservative group. For 30-day survivors, 7-year survival was 47.4% (95% CI 42.9-51.8) and 11.6% (95% CI 8.3-15.6), respectively. After multivariate adjustment, an invasive strategy was associated with lower long-term risk (adjusted HR [aHR] 0.49 [95% CI 0.41-0.59]). Actual revascularization was associated with lower risk of long-term mortality compared to angiography only (aHRPCI 0.73 [95% CI 0.59-0.90], aHRCABG 0.43 [95% CI 0.28-0.65]). CONCLUSION: In this real-life cohort of NSTEMI patients ≥75 years, 30-day survival was 95%, and 7-year survival was 47% with an invasive strategy. Revascularized patients had a superior long-term prognosis. With a conservative strategy, short- and long-term survival was lower, probably due to selection bias and unmeasured confounding.
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Kvakkestad et al. (2019) conducted a cohort in non-ST-segment elevation myocardial infarction (NSTEMI) (n=2,064). Invasive strategy vs. Conservative strategy was evaluated on 7-year survival (for 30-day survivors) (aHR 0.49, 95% CI 0.41-0.59). An invasive strategy in NSTEMI patients ≥75 years was associated with a lower long-term risk of death compared to a conservative strategy (adjusted HR 0.49; 95% CI 0.41-0.59).
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