Key result
Invasive strategy fails to reduce CV death or MI in cognitively impaired older NSTEMI patients.
Why the study?
Older adults with NSTEMI and cognitive impairment face higher cardiovascular risk than those with normal cognition, yet it remains unclear how cognition should guide the choice between an invasive and a conservative treatment strategy.
Does an invasive treatment strategy reduce the composite of cardiovascular death or nonfatal myocardial infarction compared to a conservative strategy in older adults with NSTEMI and cognitive impairment?
RCT (n=1,455)
randomisation
Does an invasive treatment strategy reduce the composite of cardiovascular death or nonfatal myocardial infarction compared to a conservative strategy in older adults with NSTEMI and cognitive impairment?
In older patients with NSTEMI and cognitive impairment, an invasive strategy did not significantly reduce the primary composite of cardiovascular death or nonfatal MI compared with a conservative strategy, though it was associated with an exploratory reduction in nonfatal MI.
Answers are grounded in this paper and cite their sources.
Supports conservative strategy in cognitively impaired older NSTEMI patients; extends SENIOR-RITA evidence without primary endpoint benefit from invasive approach.
BACKGROUND: Older adults with non-ST-segment elevation myocardial infarction (NSTEMI) and cognitive impairment experience higher cardiovascular risk than patients with normal cognition. It remains unclear how cognition should influence whether older adults receive an invasive or conservative treatment strategy. OBJECTIVES: To compare an invasive and conservative treatment strategy among older adults with NSTEMI and cognitive impairment. METHODS: This study is a pre-specified analysis of the SENIOR-RITA randomised controlled trial. Cognition was measured at randomisation using the Montreal Cognitive Assessment (MoCA). Patients were followed up for a median of 4.1 years postrandomisation. The primary outcome was a composite of time to cardiovascular death or nonfatal myocardial infarction (MI). RESULTS: MoCA was available for 1455 patients (95.8%) who underwent randomisation. Within the cognitively impaired group (909 patients), the primary outcome occurred in 116 patients (26.8%) in the invasive group and in 141 patients (29.6%) in the conservative group (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.66 to 1.10; P = 0.20). Nonfatal MI occurred in 48 patients (11.1%) in the invasive group and in 75 patients (15.8%) in the conservative group (HR 0.64; 95% CI, 0.44 to 0.92). However, there was no interaction between treatment strategy and cognition. CONCLUSIONS: Among those with evidence of cognitive impairment at randomisation, an invasive treatment strategy did not reduce the primary composite outcome of cardiovascular death or nonfatal MI, and there was no evidence of treatment effect heterogeneity based on cognition. The reduction in nonfatal MI events among those with cognitive impairment should be interpreted as an exploratory finding.
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Gill et al. (2026) conducted an RCT in Non-ST-segment elevation myocardial infarction (NSTEMI) with cognitive assessment (n=1,455). Invasive treatment strategy vs. Conservative treatment strategy was evaluated on Composite of time to cardiovascular death or nonfatal myocardial infarction (MI) in the cognitively impaired group (HR 0.85, 95% CI 0.66-1.10, p=0.20). An invasive strategy did not reduce CV death or nonfatal MI vs conservative strategy in cognitively impaired older NSTEMI patients.
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