Does a routine invasive strategy produce better outcomes than medical management in older, frail patients with non-ST segment elevation myocardial infarction?
In this study of older patients with frailty who present with NSTEMI, a routine invasive strategy was no different than medical therapy in improving outcomes. However, there were a few limitations to this study, including lack of full power, a potential selection bias, and baseline characteristics between the study groups that were not completely balanced. A larger randomized trial is needed to determine whether medical management alone is adequate in these patients.
Randomized controlled trial (nonblinded)
Inpatient (any location) with outpatient follow-up
In this multicenter study from Spain, investigators recruited patients 70 years and older who were admitted to the hospital with non-ST segment elevation myocardial infarction (NSTEMI) and had a score of at least 4 on the Clinical Frailty Scale (range 1 - 9; higher scores represent greater frailty). Patients were randomized, using concealed allocation, to receive either a routine invasive strategy of coronary angiography within 72 hours of admission (n = 84) or a conservative strategy of medical management (n = 83). Patients in the conservative group were allowed to undergo subsequent cardiac catheterization in the case of recurrent ischemia. The treating physician was responsible for considering the patient for enrollment in the trial, which may have resulted in a selection bias. The mean age of the study population was 86 years, and the mean frailty score was 5.1. The conservative group had a higher proportion of men (57% vs 38%), previous myocardial infarctions (39% vs 23%), and previous percutaneous coronary intervention (40% vs 23%). For the primary outcome of days alive and out of the hospital and the coprimary outcome of major ischemic cardiac events, there were no significant differences between the 2 groups. This remained true in sensitivity analyses stratified by sex and the Charlson Comorbidity Index. Despite the lack of statistical significance, the study suggested that conservative management led to approximately one month more of out-of-hospital survival (28 days; 95% CI -7 to 62 days) and invasive management was associated with a 28-day shorter survival duration during the first year (-63 to 7 days). Although the trial was prematurely terminated because of poor enrollment during the COVID-19 pandemic and the target sample size of 88 patients per group was not reached, the trend in the results does not point to the invasive management strategy being more effective, and it is doubtful that 4 or 5 more patients in each group would have tipped the scales in favor of the invasive approach.
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine