Early Aggressive Versus Initially Conservative Treatment in Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndrome: A Randomized Controlled Trial

Study Questions:

What is the risk versus benefit ratio of an early aggressive (EA) approach in elderly patients with non─ST-segment elevation acute coronary syndromes (NSTE-ACS)?

Methods:

Three hundred thirteen patients ≥75 years of age (mean 82 years) with NSTE-ACS within 48 hours from qualifying symptoms were randomly allocated to an EA strategy (coronary angiography and, when indicated, revascularization within 72 hours) or an initially conservative (IC) strategy (angiography and revascularization only for recurrent ischemia). The primary endpoint was the composite of death, myocardial infarction, disabling stroke, and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year.

Results:

During admission, 88% of the patients in the EA group underwent angiography (55% revascularization) compared with 29% (23% revascularization) in the IC group. The primary outcome occurred in 43 patients (27.9%) in the EA group and 55 (34.6%) in the IC group (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.53-1.19; p = 0.26). The rates of mortality (HR, 0.87; 95% CI, 0.49-1.56), myocardial infarction (HR, 0.67; 95% CI, 0.33-1.36), and repeat hospital stay (HR, 0.81; 95% CI, 0.45-1.46) did not differ between groups. The primary endpoint was significantly reduced in patients with elevated troponin on admission (HR, 0.43; 95% CI, 0.23-0.80), but not in those with normal troponin (HR, 1.67; 95% CI, 0.75-3.70; p for interaction = 0.03).

Conclusions:

The authors concluded that the present study does not allow a definite conclusion about the benefit of an EA approach among elderly patients with NSTE-ACS.

Perspective:

This underpowered study does not allow a definite conclusion about the benefit of an EA approach when applied systematically among elderly patients with NSTE-ACS. The finding of a significant interaction for the treatment effect according to troponin status at baseline, with benefit confined in troponin-positive patients, should be confirmed in a larger-sized trial. If an adequately powered trial shows significant clinical benefits, then a routine invasive strategy may be considered reasonable in very elderly patients admitted with NSTE-ACS and positive biomarkers.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, ACS and Cardiac Biomarkers, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Stroke, Biological Markers, Coronary Angiography, Troponin


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