Invasive Strategy Is No Better Than Conservative Strategy for Older Patients With NSTEMI

Is an invasive strategy more effective than a conservative strategy for the management of non–ST-segment elevation myocardial infarction (NSTEMI) in older adults?

An early invasive strategy for older patients with acute NSTEMI did not improve outcomes overall. Although there were significantly fewer nonfatal myocardial infarctions (MIs) with the early invasive strategy (11.7% vs 15.0%), there was no difference in all-cause mortality between groups, and the invasive strategy group had slightly more cardiovascular deaths (this was not statistically significant). (Level of Evidence = 1b)

The researchers recruited patients 75 years and older with NSTEMI and randomized them to receive invasive or conservative strategies. At baseline, the mean age of participants was 82 years, 45% were women, and slightly more than 20% were assessed as being frail. The invasive treatment group received invasive coronary angiography and, if indicated, revascularization plus best available medical therapy, which included aspirin, a P2Y12 receptor antagonist, statin, beta blocker, an angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker; the conservative treatment group received only best available medical therapy. Approximately one-half of the invasive treatment group was revascularized, with almost all of those patients undergoing percutaneous intervention. After a median 4.1 years of follow-up, the primary outcome of cardiovascular death or nonfatal MI was similar between groups (25.6% for invasive vs 26.3% for conservative; hazard ratio = 0.94; 95% CI, 0.77–1.14). Although there were significantly fewer nonfatal MIs in the invasive strategy group (11.7% vs 15.0%), there were more cardiovascular deaths (15.8% vs 14.2%; hazard ratio = 1.11; 95% CI, 0.86–1.44). There was no difference in all-cause mortality.

Study design: Randomized controlled trial (nonblinded)

Funding source: Foundation

Allocation: Concealed

Setting: Outpatient (specialty)

Reference: Kunadian V, Mossop H, Shields C, et al.; British Heart Foundation SENIOR-RITA Trial Team and Investigators. Invasive treatment strategy for older patients with myocardial infarction. N Engl J Med. 2024;391(18):1673-1684.

Editor’s Note: Dr. Ebell is deputy editor for evidence-based medicine for AFP and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell.