NSTEMI chez la personne âgée et fragile : l’approche invasive est-elle toujours recommandée ?
Key result
Invasive strategy fails to reduce CV death or non-fatal MI in frail older NSTEMI patients.
Why the study?
The effects of an invasive strategy compared to conservative treatment in frail elderly patients with NSTEMI were uncertain.
Does an invasive strategy reduce cardiovascular death or non-fatal myocardial infarction in frail elderly patients with NSTEMI?
Key Points
- To determine whether a routine invasive coronary strategy improves cardiovascular outcomes compared to conservative management in frail older adults presenting with NSTEMI.
- Prespecified exploratory subgroup analysis of frail older adults (N=469, median age 83 years, 51.2% female, age >75 years) classified by the Fried frailty scale within a randomized trial.
- Participants received either an immediate invasive strategy (prompt coronary angiography and revascularization if indicated; n=231) or a conservative medical strategy (n=238).
- The primary endpoint of cardiovascular death or nonfatal myocardial infarction occurred in 37.7% (87/231) of the invasive group versus 29.4% (70/238) of the conservative group (HR: 1.21; 95% CI: 0.88–1.67).
- Major bleeding occurred in 7.3% of the invasive arm compared with 3.9% of the conservative arm (HR: 2.26; 95% CI: 0.80–6.51).
- Secondary coronary angiographies were required less often in the invasive group than in the conservative group (10.0% vs 30.7%; HR: 0.28; 95% CI: 0.16–0.51).
Study Design
Type
RCT (n=469)
Randomization
Randomized
Structured PICO
Does an invasive strategy reduce cardiovascular death or non-fatal myocardial infarction in frail elderly patients with NSTEMI?
P
Population
469 frail older adults (age >75 years, median age 83) with NSTEMI from a randomized trial.
I
Intervention
Invasive strategy consisting of early coronary angiography and revascularization if needed.
C
Comparator
Conservative treatment.
O
Outcome
Composite of cardiovascular death or non-fatal myocardial infarction.composite
Main Result
Hazard Ratio: 1.21 (95% CI 0.88–1.67)
Absolute Event Rate: 37.7% vs 29.4%
An invasive strategy in frail elderly patients with NSTEMI does not improve cardiovascular mortality or non-fatal myocardial infarction outcomes compared to conservative management and may increase bleeding risk.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We are limited by this analysis. SENIOR-RITA is the largest clinical trial in older adults with non-ST-elevation myocardial infarction where they systematically collected frailty and multimorbidity [data].... We really do need more trials in frail patients otherwise we'll not have generalized evidence in the field.”
“A superficial reading of the findings from the Older Patients with Non-ST-SEgmeNt elevatiOn myocaRdial Infarction Randomized Interventional TreAtment (SENIOR-RITA) Trial may lead one to believe that, in older patients (≥75 years) presenting with non-ST-segment elevation myocardial infarction (NSTEMI), an initial conservative approach should be preferred. This is probably a misleading interpretation.”
AAAnthony A. BavryCardiologist, University of Florida
“Among individuals ≥75 years of age, routine invasive therapy can be performed but needs to be individualized according to angina burden, coronary anatomy complexity, clinical conditions suggesting high risk (ventricular arrhythmia, left ventricular systolic dysfunction), and overall shared decision making.”
Implication
Exploratory frailty subgroup analysis in elderly NSTEMI; leaves open whether invasive strategy improves outcomes in this population.
Abstract
Cette analyse exploratoire prédéfinie d’un sous-groupe de patients âgés présentant un NSTEMI (infarctus du myocarde sans sus-décalage du segment ST) enrôlés dans un essai randomisé a évalué les effets d’une stratégie invasive par rapport à un traitement conservateur chez les patients fragiles, selon l’échelle de Fried. La stratégie invasive consistait en une coronarographie d’emblée et une revascularisation au besoin. Parmi les participants à l’essai initial âgés de plus de 75 ans, 469 (32,4 %) présentaient des critères de fragilité avec un âge médian de 83 ans, et 240 (51,2 %) étaient de sexe féminin. L’événement primaire – un décès d’origine cardiovasculaire ou un infarctus non fatal – est survenu chez 87 des 231 participants (37,7 %) dans le groupe invasif et chez 70 des 238 participants (29,4 %) du groupe de traitement conservateur (HR : 1,21 ; IC 95 % : 0,88-1,67). Durant le suivi, le groupe invasif présentait plus de saignements (7,3 vs 3,9 %, HR : 2,26 ; IC 95 % : 0,80-6,51), mais moins de coronarographies secondaires (10,0 vs 30,7 % ; HR : 0,28 ; IC 95 % : 0,16-0,51). Les auteurs ont conclu que la stratégie invasive chez les patients fragiles n’apporte pas de bénéfice en termes de mortalité cardiovasculaire et d’infarctus non fatal.
Discussion
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Cite This Study
Grandmaison et al. (2026) conducted an RCT in NSTEMI with frailty (n=469). Invasive strategy (immediate coronary angiography and revascularization if needed) vs. Conservative treatment was evaluated on Cardiovascular death or non-fatal myocardial infarction (HR 1.21, 95% CI 0.88-1.67). An invasive strategy for NSTEMI in frail older patients did not reduce cardiovascular death or non-fatal MI vs conservative care (37.7% vs 29.4%; HR 1.21; 95% CI 0.88-1.67).