Key result
Invasive strategy in older NSTEMI patients linked to ~47% lower 1-year MACCE vs conservative care.
Why the study?
The optimal management of elderly patients with NSTEMI remains uncertain, particularly among those with frailty, and whether frailty modifies the treatment effect of an invasive strategy was unclear.
Does an invasive strategy reduce 1-year major adverse cardiovascular and cerebrovascular events compared to conservative management in patients aged ≥70 years with NSTEMI across different frailty levels?
Cohort (n=15,537)
Yes
Does an invasive strategy reduce 1-year major adverse cardiovascular and cerebrovascular events compared to conservative management in patients aged ≥70 years with NSTEMI across different frailty levels?
In patients aged ≥70 years with NSTEMI, an invasive strategy is associated with reduced 1-year cardiovascular events and mortality in non-frail to moderately frail patients (CFS 1–6), whereas the benefit is attenuated and not statistically significant in severely frail patients (CFS 7–8).
May support invasive strategy in non-severely frail elderly NSTEMI patients; leaves open confirmation of net benefit in severe frailty by randomized trials.
Background The optimal management of elderly patients with non-ST-elevation myocardial infarction (NSTEMI) remains uncertain, particularly among those with frailty. Purpose We aimed to evaluate the association between an invasive strategy and 1-year outcomes in patients aged ≥70 years, and whether frailty modifies the treatment effect. Methods We included 15,537 patients aged ≥70 years with NSTEMI from 2017 to 2021; 11,743 (75.6%) underwent invasive coronary angiography, while 3,794 (24.4%) were managed conservatively. Frailty was assessed using the Clinical Frailty Scale (CFS) and categorized as 1–3 (no-frail) 4 (vulnerable), 5–6 (mildly-moderately frail), and 7–8 (severely and very severely frail) . Outcomes included 1-year major adverse cardiovascular and cerebrovascular events (MACCE), all-cause mortality, and readmission for MI or stroke. To address confounding, we performed instrumental variable (IV) analysis using a two-stage residual inclusion Cox regression with the leave-one-out centre angiography rate as the instrument, and propensity score matching (PSM). Results In IV-adjusted models, an invasive strategy was associated with significantly lower risk of 1-year MACCE (HR 0.53, 95% CI 0.44–0.64), mortality (HR 0.47, 95% CI 0.38–0.60), and MI (HR 0.44, 95% CI 0.30–0.64), with no significant effect on stroke (HR 0.84, 95% CI 0.41–1.72). PSM analyses confirmed these results (table 1). The reduction in MACCE with an invasive strategy was observed in patients without or moderate frailty (CFS 1–6), but the benefit decreased as frailty increased (interaction p=0.01) and was not statistically significant in severely frail patients (CFS 7–8; HR 0.68, 95% CI 0.48–1.06) (table 2). Conclusion Among elderly patients with NSTEMI, an invasive strategy was associated with lower 1-year risk of cardiovascular events, including those with moderate frailty (CFS 5–6). In severely frail patients (CFS 7–8), the benefit was numerically lower but not statistically significant. These findings support considering angiography in selected older adults, with individualized risk assessment based on frailty.Outcomes
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Venetsanos et al. (2026) conducted a cohort in Non-ST-elevation myocardial infarction (NSTEMI) (n=15,537). Invasive coronary angiography strategy vs. Conservative management was evaluated on 1-year major adverse cardiovascular and cerebrovascular events (MACCE) (HR 0.53, 95% CI 0.44-0.64). An invasive strategy in NSTEMI patients ≥70 years was associated with lower 1-year MACCE vs conservative care (HR 0.53; 95% CI 0.44–0.64), though attenuated in severe frailty (interaction p=0.01).
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