Key result
Routine invasive management fails to reduce reinfarction vs. conservative care in frail older NSTEMI patients.
Why the study?
Clinical trials and meta-analyses indicate reduced reinfarction risk with invasive management in older NSTEMI patients, but benefits in frail patients remain unclear.
Does a newly developed logistic regression model improve the prediction of 30-day complications in ED patients with ACS compared to existing risk scores?
RCT (n=167)
randomised to invasive (n=84) or conservative (n=83) strategy
Does a newly developed logistic regression model improve the prediction of 30-day complications in ED patients with ACS compared to existing risk scores?
Answers are grounded in this paper and cite their sources.
Routine invasive management confers no reinfarction benefit in frail older NSTEMI patients; challenges routine use and supports conservative strategies in this population.
BACKGROUND: Clinical trials and meta-analyses indicate a reduced reinfarction risk with invasive management in older patients with non-ST-segment elevation myocardial infarction (NSTEMI). This study investigated whether similar benefits might be observed in frail patients. METHODS: The coMOrbilidades Síndrome Coronario Agudo - FRAIL (MOSCA-FRAIL) trial included 167 adults aged ≥70 years with frailty (Clinical Frailty Scale ≥4 points) and NSTEMI, who were randomised to invasive (n=84) or conservative (n=83) strategy during the index hospitalisation. The primary end point of this subanalysis was reinfarction, considering all-cause mortality as a competing event, at a 3-year median follow-up. The time to first reinfarction and all reinfarctions (first and recurrent) were considered. The substudy was not prespecified. RESULTS: The total number of deaths (93, 56%) exceeded that of first reinfarctions (32, 19%). Invasive treatment did not influence the reinfarction risk when accounting for death as a competing risk (subdistribution HR=0.87, 95% CI 0.54 to 1.40, p=0.56). An initially increased mortality risk with invasive management (significant between days 131 and 175) shifted to a lower mortality risk over time. A total of 45 reinfarctions (first and recurrent) were observed. The longitudinal trajectories corroborated that the invasive strategy did not reduce the risk of reinfarction over time (p=0.72). However, mortality followed a biphasic pattern, with higher mortality in the invasive group during the first 6 months and a reduction between 9 months and 3 years (p=0.05 for the entire time-dependent trajectory). The win ratio for the invasive strategy versus the conservative strategy was 1.08 (95% CI 0.72 to 1.63, p=0.70). CONCLUSIONS: In older adults with frailty and NSTEMI, routine invasive management did not reduce the reinfarction risk at a 3-year follow-up. The high all-cause mortality associated with frailty may limit the impact of invasive management. Due to the limited sample size and risk for type II error, these findings should be considered hypothesis-generating. TRIAL REGISTRATION NUMBER: NCT03208153.
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Sanchís et al. (2025) conducted an RCT in Non-ST-segment elevation myocardial infarction (NSTEMI) with frailty (n=167). Routine invasive management vs. Conservative strategy was evaluated on Reinfarction, considering all-cause mortality as a competing event (subdistribution HR 0.87, 95% CI 0.54-1.40, p=0.56). Routine invasive management did not reduce the risk of reinfarction compared to a conservative strategy in older adults with frailty and NSTEMI (HR 0.87, 95% CI 0.54-1.40, p=0.56).
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