The world population is aging, and cardiovascular diseases are the leading cause of death in Western countries.
It is increasingly common to find patients aged 70 or older with non-ST-segment elevation acute myocardial infarction (NSTEMI). However, this group has been excluded from most studies, and there is not enough information to determine whether a conservative approach or invasive studies should be the preferred option.
Researchers conducted a meta-analysis including 1479 patients, half of whom underwent invasive treatment (INV) while the other half received conservative treatment (CON).
The primary endpoint (PEP) was all-cause mortality or myocardial infarction at one year of follow-up.
There were no significant differences in the studied population: the mean age was 84 years and 52% of patients were men; 79% had hypertension, 29% had diabetes, 15% had suffered a stroke, 35% had a previous myocardial infarction, 20% had undergone percutaneous coronary intervention (PCI), 13% had undergone myocardial revasculatization surgery, and 15% had atrial fibrillation.
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There were also no differences in the Killip classification at admission; most subjects were in Killip class 1.
The PEP at one year was similar between groups: 24.5% in the INV group and 28.9% in the CON group (95% confidence interval [CI]: 0.63–1.22; P = 0.43). There were no differences in mortality, but patients who received conservative treatment had a higher rate of myocardial infarction (19.1% vs. 12.2%, 95% CI 0.47–0.79; P = 0.0002) and a greater need for urgent revascularization (random-effects model hazard ratio [HR]: 0.41; 95% CI, 0.18–0.95; P = 0.037).
Conclusion
There was no evidence that routine invasive treatment in elderly patients with NSTEMI reduces the risk of all-cause mortality or myocardial infarction within one year compared with conservative treatment. However, there is compelling evidence that invasive treatment reduces the risk of recurrent myocardial infarction or need for urgent revascularization. More research through large-scale studies is needed.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Invasive vs. conservative management of older patients with non-ST-elevation acute coronary syndrome: individual patient data meta-analysis.
Reference: Christos P. Kotanidis, et al. European Heart Journal (2024) 45, 2052–2062 https://doi.org/10.1093/eurheartj/ehae151
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