Invasive Treatment Strategy for Older Patients with Myocardial Infarction

• Published in: The New England journal of medicine
• Main Authors: Kunadian, Vijay, Mossop, Helen, Shields, Carol, Bardgett, Michelle, Watts, Philippa, Teare, M Dawn, Pritchard, Jonathan, Adams-Hall, Jennifer, Runnett, Craig, Ripley, David P, Carter, Justin, Quigley, Julie, Cooke, Justin, Austin, David, Murphy, Jerry, Kelly, Damian, McGowan, James, Veerasamy, Murugapathy, Felmeden, Dirk, Contractor, Hussain, Mutgi, Sanjay, Irving, John, Lindsay, Steven, Galasko, Gavin, Lee, Kelvin, Sultan, Ayyaz, Dastidar, Amardeep G, Hussain, Shazia, Haq, Iftikhar Ul, de Belder, Mark, Denvir, Martin, Flather, Marcus, Storey, Robert F, Newby, David E, Pocock, Stuart J, Fox, Keith A A
• Format: Journal Article
• Language: English
• Published: United States 01.09.2024
• ISSN: 1533-4406
• DOI: 10.1056/NEJMoa2407791

Whether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear. We conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis. A total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P = 0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients. In older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.).