Effects of Age on Long-Term Outcomes After a Routine Invasive or Selective Invasive Strategy in Patients Presenting With Non-ST Segment Elevation Acute Coronary Syndromes: A Collaborative Analysis of Individual Data From the FRISC II - ICTUS - RITA-3 (FIR) Trials

Study Questions:

Does age influence the risk-benefit ratio of early invasive versus selective invasive strategy in patients presenting with non–ST-elevation acute coronary syndromes (NSTE-ACS)?


The authors performed a pooled patient-level meta-analysis of FRISC II, ICTUS, and RITA-3 studies. Unadjusted and adjusted hazard ratios were calculated by Cox regression, with adjustments for variables associated with age and outcomes. The main outcome was 5-year cardiovascular death or myocardial infarction (MI) following routine invasive versus selective invasive management.


The combined data set had 5,467 patients. At 5-year follow-up, 74.1% of the patients in the early invasive arm underwent revascularization by percutaneous coronary intervention or CABG, whereas 49.6% underwent revascularization in the selective invasive strategy group. The routine invasive strategy was associated with a lower hazard of death or MI in patients ages 65-74 years (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.58-0.90) and those ages ≥75 years (HR, 0.71; 95% CI, 0.55-0.91), but not in those ages <65 years (HR, 1.11; 95% CI, 0.90-1.38), p = 0.001 for interaction between treatment strategy and age. The interaction was driven by an excess of early MIs in patients <65 years of age. Overall, there was no difference in mortality. The benefits were smaller for women than for men (p = 0.009 for interaction).


The authors concluded that the benefit of early invasive strategy was attenuated in younger patients with NSTE-ACS.


This study found that the benefit of early invasive strategy is attenuated in younger patients due to an excess of MIs in this group. However, long-term, there was no difference in survival among young patients who were treated with an early invasive or a selective invasive strategy. More importantly, the authors found that older patients had significantly better outcome with an early invasive approach, suggesting that age alone should not be a bar to an invasive approach in patients with ACS.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Interventions and ACS

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Death, Cardiology, Myocardial Revascularization, Cardiovascular Diseases, Confidence Intervals, Angioplasty, Balloon, Coronary, Percutaneous Coronary Intervention

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