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Invasive vs. Conservative Management of Older Patients With NSTE-ACS
Quick Takes
- The current study used individual patient-level data and the authors performed a meta-analysis of RCTs evaluating conservative vs. routine invasive management among older patients presenting with NSTE-ACS. Six trials were included spanning 2010–2021.
- There was no significant difference in all-cause mortality (HR, 1.03; 95% CI, 0.69–1.53) or cardiovascular mortality (HR, 0.89; 95% CI, 0.57–1.40) among the two treatment strategies. However, patients undergoing an invasive approach had lower rates of MI (HR, 0.62; 95% CI, 0.44–0.87) and unplanned revascularization (HR, 0.41; 95% CI, 0.18–0.95) at 1 year.
Study Questions:
What is the impact of routine invasive versus conservative management of non–ST-elevation acute coronary syndrome (NSTE-ACS) in older patients?
Methods:
Individual patient data from six randomized controlled trials (RCTs) investigating routine invasive and conservative strategies in persons >70 years old with NSTE-ACS from 2008–2021 were included for this analysis. The primary endpoint was a composite of all-cause mortality and myocardial infarction (MI) at 1 year. One-stage individual patient data meta-analyses were adopted by use of random-effects and fixed-effect Cox models.
Results:
Six eligible studies were identified including 1,479 participants. The primary endpoint occurred in 181 of 736 (24.5%) participants in the invasive management group compared with 215 of 743 (28.9%) participants in the conservative management group with a hazard ratio (HR) from random-effects model of 0.87 (95% confidence interval [CI], 0.63–1.22; p = 0.43). The hazard for MI at 1 year was significantly lower in the invasive group compared with the conservative group (HR from random-effects model, 0.62; 95% CI, 0.44–0.87; p = 0.006). Similar results were seen for urgent revascularization (HR from random-effects model, 0.41; 95% CI, 0.18–0.95; p = 0.037). There was no significant difference in mortality.
Conclusions:
No evidence was found that routine invasive treatment for NSTE-ACS in older patients reduces the risk of a composite of all-cause mortality and MI within 1 year compared with conservative management. However, there is convincing evidence that invasive treatment significantly lowers the risk of repeat MI or urgent revascularization. Further evidence is needed from ongoing larger clinical trials.
Perspective:
Management of older adults with NSTE-ACS remains debated given competing risks and benefits of invasive therapies. The current study used individual patient-level data and the authors performed a meta-analysis of RCTs evaluating conservative versus routine invasive management among older patients presenting with NSTE-ACS. Six trials were included spanning 2010–2021. There was no significant difference in all-cause mortality (HR, 1.03; 95% CI, 0.69–1.53) or cardiovascular mortality (HR, 0.89; 95% CI, 0.57–1.40) among the two treatment strategies. However, patients undergoing an invasive approach had lower rates of MI (HR, 0.62; 95% CI, 0.44–0.87) and unplanned revascularization (HR, 0.41; 95% CI, 0.18–0.95) at 1 year. Limitations of the current analysis include absence of bleeding or complication rates, which can be elevated in older adults, inclusion of studies from less contemporary trials that may not be reflective of current practice, and inclusion of a heterogenous group of the NSTE-ACS patient population (troponin-positive and troponin-negative patients). Management of older adults with NSTE-ACS is challenging and continues to require assessment of individual patient risks, benefits, and preferences.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Stable Ischemic Heart Disease, Vascular Medicine, Chronic Angina, Invasive Cardiovascular Angiography and Intervention
Keywords: Acute Coronary Syndrome, Non-ST Elevated Myocardial Infarction
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