Invasive vs. Conservative Strategy in Patients Over 80 Years With Non–ST-Elevation Myocardial Infarction or Unstable Angina Pectoris - After Eighty Study

Mar 22, 2016
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Presenter/Author:
Nicolai Kloumann Tegn, MD
Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Norwegian Health Association (ExtraStiftelsen), Inger and John Fredriksen Heart Foundation
Date Presented:
03/16/2015
Date Published:
03/12/2016
Original Posted Date:
03/22/2016
References

Description:

The goal of the trial was to evaluate invasive versus conservative therapy among the elderly (aged 80 years or older) with non-ST-elevation acute coronary syndrome (NSTE-ACS).

Contribution to the Literature: The After Eighty study showed that invasive therapy reduced adverse cardiovascular events among the elderly compared with conservative therapy.

Study Design


  • Randomized
  • Parallel

Elderly patients patients (≥80 years) with NSTE-ACS were randomized to invasive therapy (n = 229) versus conservative therapy (n = 228). In the invasive arm, the mean time to angiography was 3 days. Both groups received aspirin and clopidogrel.

Patient population:

  • Total number of enrollees: 457
  • Duration of follow-up: median 1.5 years
  • Mean patient age: 85 years
  • Percentage female: 45%
  • Percentage diabetics: 20%
  • Other: 94% had an elevated troponin at presentation

Inclusion criteria:

  • Patients ≥80 years with NSTE-ACS

Exclusion criteria:

  • Clinical instability
  • Refractory chest pain, cardiogenic shock
  • Ongoing bleeding problems
  • Limited life expectancy
  • Significant mental disorder that impaired with patient’s capacity to provide informed consent

Principal Findings:

The primary outcome of death, myocardial infarction (MI), stroke, or urgent revascularization occurred in 41% of the invasive group versus 61% of the conservative group (p < 0.0001). Invasive therapy was beneficial for patients ≤90 years (hazard ratio 0.47), while it appeared harmful for patients >90 years (hazard ratio 1.21, p for interaction = 0.033).

Secondary outcomes:

  • Death: 25% vs. 27% (p = 0.53), respectively, for invasive vs. conservative therapy
  • MI: 17% vs. 30% (p = 0.0003), respectively, for invasive vs. conservative therapy
  • Stroke: 3% vs. 6% (p = 0.26), respectively, for invasive vs. conservative therapy
  • Major bleeding: 2% vs. 2%, respectively, for invasive vs. conservative therapy

Interpretation:

Among elderly patients with NSTE-ACS, invasive therapy was beneficial at reducing adverse cardiovascular events compared with conservative therapy. This was due to a reduction in recurrent MI and urgent revascularization procedures. There was suggestion of harm for patients >90 years of age; however, definitive conclusions in this group were not possible due to the limited number of patients. This trial is unique in that no crossovers occurred between the treatment groups, unlike previous trials in which a large proportion of conservative patients underwent angiography. Elderly patients are at high risk for adverse events after a NSTE-ACS, and invasive therapy remains the optimal treatment to reduce this risk.

References:

Tegn N, Abdelnoor M, Aaberge L, et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial. Lancet 2016;387:1057-65.

Presented by Dr. Nicolai Tegn at ACC.15, San Diego, CA, March 16, 2015.

Keywords: ACC Annual Scientific Session, Acute Coronary Syndrome, Aged, Aged, 80 and over, Angina Pectoris, Angina, Unstable, Coronary Angiography, Coronary Artery Bypass, Geriatrics, Myocardial Infarction, Stroke


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