Publication: Invasive vs. conservative management of older patients with non-ST-elevation acute coronary syndrome: individual patient data meta-analysis
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Date
2024
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Background and Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) are less likely to receive guideline-Aims recommended care including coronary angiography and revascularization. Evidence-based recommendations regarding interventional management strategies in this patient cohort are scarce. This meta-analysis aimed to assess the impact of routine invasive vs. conservative management of NSTEACS by using individual patient data (IPD) from all available randomized controlled trials (RCTs) including older patients Methods MEDLINE, Web of Science and Scopus were searched between 1 January 2010 and 11 September 2023. RCTs investigating routine invasive and conservative strategies in persons >70 years old with NSTEACS were included. Observational studies or trials involving populations outside the target range were excluded. The primary endpoint was a composite of all-cause mortality and myocardial infarction (MI) at 1 year. One-stage IPD meta-analyses were adopted by use of random-effects and fixed-effect Cox models. This meta-analysis is registered with PROSPERO (CRD42023379819) Results Six eligible studies were identified including 1479 participants. The primary endpoint occurred in 181 of 736 (24.5%) participants in the invasive management group compared with 215 of 743 (28.9%) participants in the conservative management group with a hazard ratio (HR) from random-effects model of 0.87 (95% CI 0.63–1.22; P = .43). The hazard for MI at 1 year was significantly lower in the invasive group compared with the conservative group (HR from random-effects model 0.62, 95% CI 0.44–0.87; P = .006). Similar results were seen for urgent revascularization (HR from random-effects model 0.41, 95% CI 0.18–0.95; P = .037). There was no significant difference in mortality Conclusions No evidence was found that routine invasive treatment for NSTEACS in older patients reduces the risk of a composite of all-cause mortality and MI within 1 year compared with conservative management. However, there is convincing evidence that invasive treatment significantly lowers the risk of repeat MI or urgent revascularisation. Further evidence is needed from ongoing larger clinical trials. Structured Graphical Abstract Key Question Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) are less likely to receive coronary angiography and revascularization. Evidence-based recommendations regarding interventional strategies are scarce. The present study compared routine invasive with conservative management of older patients with NSTEACS using individual patient data from all contemporary randomized controlled trials. Key Finding At one-year follow-up, routine invasive management was associated with a significantly reduced risk of myocardial infarction or urgent revascularization. No benefit was observed for mortality or a composite of all-cause mortality and myocardial infarction. Take Home Message This study provides robust evidence that a routine invasive strategy is superior to conservative approaches in reducing the risk of myocardial infarction and urgent revascularization at one year. It supports the consideration of routine invasive management in older patients with NSTEACS. Individual patient data from six randomized controlled trials 313 457 106 186 250 167 Italian Elderly ACS After Eighty MOSCA 80+ study RINCAL MOSCA-FRAIL 1479 Routine invasive strategy Initial conservative strategy 736 743 One-year outcomes Composite of all-cause mortality and MI - random effects HR 0.87 (95% CI 0.63–1.22) Composite of all-cause mortality and MI - fixed effects HR 0.82 (95% CI 0.67–1.00) All-cause mortality HR 1.03 (95% CI 0.69–1.53) Cardiovascular mortality HR 0.89 (95% CI 0.57–1.40) MI HR 0.62 (95% CI 0.44–0.87) Urgent revascularization HR 0.41 (95% CI 0.18–0.95) Composite of all-cause mortality and MI - troponin positive HR 0.81 (95% CI 0.58–1.12) Composite of all-cause mortality and MI - troponin negative HR 1.71 (95% CI 0.69–4.25) Using individual patient-level data we show that the risk of myocardial infarction and unplanned urgent revascularization is lower in older patients with non-ST-elevation acute coronary syndrome (NSTEACS) treated with a routine invasive strategy compared to a conservative medical approach. The risk of a composite endpoint of all-cause mortality and reinfarction showed weaker evidence of a potentially lower risk for an invasive strategy, while we observed no evident difference for all-cause mortality, cardiovascular death, and stroke. CI, confidence interval; HR, hazard ratio; MI, myocardial infarction. © 2024 Oxford University Press. All rights reserved.
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Keywords
Acute coronary syndrome, Coronary angiography, Myocardial infarction, Older adults, Percutaneous coronary intervention