Key result
Invasive management reduced the risk of myocardial infarction compared with conservative management in patients aged ≥75 years with NSTEMI in pooled RCTs (OR 0.51, 95% CI 0.40-0.65).
Why the study?
The study aimed to evaluate the real-world management and outcomes of octogenarian patients with NSTEMI, including the impact of coronary angiography timing.
Does an invasive management strategy (PCI/CABG) reduce all-cause mortality, myocardial infarction, stroke, or major bleeding compared with conservative management in patients aged ≥75 years with NSTEMI?
Meta-Analysis (n=1,017,374)
Yes
Does an invasive management strategy (PCI/CABG) reduce all-cause mortality, myocardial infarction, stroke, or major bleeding compared with conservative management in patients aged ≥75 years with NSTEMI?
Invasive management in NSTEMI patients aged ≥75 years solidly reduces myocardial infarction, MACE, and repeat revascularization in RCTs and improves survival in pooled adjusted analyses, though caution is warranted in patients ≥85 years due to an increased risk of major bleeding.
OBJECTIVES: We aimed to evaluate the management and outcomes of patients of the octogenarian age group with non-ST elevation myocardial infarction (NSTEMI) in a real-world setting. METHODS: The risk of 30-day and 1-year mortality by age and the time of coronary angiography [categorized as early (≤48 h of admission) and late (>48 h of admission)] was assessed among 2021 NSTEMI patients enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) between 2004 and 2008. RESULTS: Elderly patients (≥80 years) comprised almost 20% of the study population, and experienced a significantly higher rate of in-hospital complications. The risk of 1-year mortality was 3.4-fold (P<0.001) higher among octogenarian patients compared with younger patients. Multivariate analysis showed that among patients aged at least 80 years, utilization of revascularization was associated with a lower risk of death at 1 year [hazard ratio (HR)=0.50, P=0.004], but not at 30 days, compared with no angiography. However, referral for early coronary angiography was associated with a lower risk of death both at 30 days and at 1 year (HR=0.4, P=0.04 and HR=0.38, P=0.02, respectively). CONCLUSION: Our findings indicate that patients of the octogenarian age group comprise a high-risk subset of the NSTEMI population, in whom early referral for coronary angiography is independently associated with a lower risk of mortality at 30 days and 1 year.
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Buber et al. (2012) conducted a meta-analysis in Non-ST-segment elevation myocardial infarction (NSTEMI) in older adults (n=1,017,374). Invasive management (percutaneous coronary intervention [PCI] and/or coronary artery bypass grafting [CABG]) vs. Conservative management (selective invasive or medical therapy alone) was evaluated on Myocardial infarction (primary endpoint from pooled RCTs with Trial Sequential Analysis confirmation) (OR 0.51, 95% CI 0.40-0.65). Invasive management reduced the risk of myocardial infarction compared with conservative management in patients aged ≥75 years with NSTEMI in pooled RCTs (OR 0.51, 95% CI 0.40-0.65).
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