Older Patients With Non–ST-Segment Elevation Myocardial Infarction Randomized Interventional Treatment - SENIOR-RITA

Nov 08, 2024
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Kim A. Eagle, MD, MACC
Trial Sponsor:
British Heart Foundation
Date Presented:
09/01/2024
Date Published:
11/07/2024
Date Updated:
11/08/2024
Original Posted Date:
09/01/2024
References

Contribution To Literature:

The SENIOR-RITA trial failed to show that routine invasive therapy reduces CV death or MI compared with conservative therapy. Invasive therapy needs to be individualized in such individuals.

Description:

The goal of the trial was to evaluate routine invasive therapy compared with conservative therapy among older patients with non–ST-elevation myocardial infarction (NSTEMI).

Study Design

  • Randomized
  • Parallel

Older patients with NSTEMI were randomized to routine invasive therapy (coronary angiography and revascularization; n = 753) versus conservative therapy (n = 765).

  • Total number of enrollees: 1,518
  • Duration of follow-up: median 4.1 years
  • Mean patient age: 82 years
  • Percentage female: 45%
  • Percentage with diabetes: 31%

Inclusion criteria:

  • Patients ≥75 years of age with NSTEMI
  • Patients who were frail or had a high burden of coexisting conditions

Exclusion criteria:

  • STEMI
  • Cardiogenic shock
  • Limited life expectancy (<1 year)

Other salient features/characteristics:

  • Very fit: 13.7%
  • Well, without active disease: 17.8%
  • Well, with treated coexisting conditions: 26.3%
  • Apparently vulnerable: 21.9%
  • Frail: 32.4%
  • Cognitive impairment: 62.5%
  • Radial access: 89%
  • Revascularization: 50%
  • Conservative patients who crossed over to angiography: 24.2%
  • Conservative patients who subsequently underwent revascularization: 13.7%

Principal Findings:

The primary outcome, cardiovascular (CV) death or MI, was 25.6% in the invasive therapy group vs. 26.3% in the conservative therapy group (p = 0.53).

Secondary outcomes:

  • CV death: 15.8% in the invasive therapy group vs. 14.2% in the conservative therapy group
  • MI: 11.7% in the invasive therapy group vs. 15.0% in the conservative therapy group
  • Major bleeding: 8.2% in the invasive therapy group vs. 6.4% in the conservative therapy group

Interpretation:

Among older patients with NSTEMI, invasive therapy failed to reduce CV death or MI compared with conservative therapy over a median follow-up of 4.1 years. Major bleeding was infrequent and similar between treatment groups. Among individuals <75 years of age, routine invasive therapy is recommended to reduce adverse cardiovascular events compared with conservative management. Among individuals ≥75 years of age, routine invasive therapy can be performed but needs to be individualized according to angina burden, coronary anatomy complexity, clinical conditions suggesting high risk (ventricular arrhythmia, left ventricular systolic dysfunction), and overall shared decision making.

References:

Highlighted text has been updated as of November 7, 2024.

Kunadian V, Mossop H, Shields C, et al., for the British Heart Foundation SENIOR-RITA Trial Team and Investigators. Invasive Treatment Strategy for Older Patients With Myocardial Infarction. N Engl J Med 2024;391:1673-84.

Editorial: Biscaglia S. SENIOR-RITA — Is It All about Angiography? N Engl J Med 2024;391:1743-4.

Presented by Dr. Vijay Kunadian at the European Society of Cardiology Congress, London, UK, September 1, 2024.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Angiography, Nuclear Imaging, Acute Coronary Syndromes

Keywords: Coronary Angiography, Frail Elderly, Geriatrics, Myocardial Infarction, Myocardial Revascularization, ESC Congress, ESC24


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