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Invasive vs. Noninvasive Management of NSTEMI in Octogenarians
Quick Takes
- Octogenarians presenting with NSTEMI and undergoing invasive management had improved morbidity and mortality compared to patients who were managed conservatively after 5 years of follow-up.
- There was a 33% reduction in heart failure admissions and a 36% reduction in mortality among those treated with an invasive approach.
- Older patients presenting with NSTEMI should be considered for benefits of invasive therapies and revascularization.
Study Questions:
What are the long-term outcomes among patients ≥80 years old undergoing invasive versus noninvasive management of non-ST elevation myocardial infarction (NSTEMI)?
Methods:
SENIOR-NSTEMI was a retrospective analysis from five hospitals in the United Kingdom of patients ≥80 years old who presented with NSTEMI between 2010 and 2017. Propensity scores (patients’ estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of noninvasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or noninvasive management groups based on their propensity scores, to mitigate immortal time bias. Estimated mortality hazard ratios comparing invasive with noninvasive management and rates of hospital admissions for heart failure were estimated.
Results:
Of the 1,976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1,500 patients had a median age of 86 (interquartile range [IQR], 82-89) years, of whom 845 (56%) received noninvasive management. During median follow-up of 3.0 (IQR, 1.2-4.8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the noninvasive management group (adjusted hazard ratio, 0.68; 95% confidence interval [CI], 0.55-0.84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with noninvasive management, 0.67; 95% CI, 0.48-0.93).
Conclusions:
The survival advantage of invasive compared with noninvasive management appears to extend to patients with NSTEMI who are aged ≥80 years.
Perspective:
Management of older patients with acute MI can be challenging given that the risks, and the rewards are higher for invasively directed management. Findings from the current study, which did have a fair representation of both sexes, suggest improved mortality among octogenarians undergoing invasive management of NSTEMI. Ongoing randomized controlled trials with long-term follow-up should help definitively answer the question. In the interim, older patients presenting with NSTEMI should be assessed for benefits of invasive therapies.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Aged, 80 and over, Cardiology Interventions, Coronary Angiography, Diagnostic Imaging, Geriatrics, Heart Failure, Myocardial Infarction, Myocardial Revascularization, Patient Admission, Troponin
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