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Early invasive strategy benefits elderly patients with non-STEMI, unstable angina
SAN DIEGO — An early invasive strategy yielded better outcomes than a conservative strategy for patients aged at least 80 years with non-STEMI or unstable angina, according to the results of the After Eighty study presented at the American College of Cardiology Scientific Sessions.
Patients aged at least 80 years are underrepresented in clinical trials, and there is little consensus on whether they should be managed with an invasive or conservative strategy when they present with non-STEMI or unstable angina, Nicolai K. Tegn, MD, said at a press conference.
Nicolai K. Tegn
Tegn, a cardiologist at Rikshospitalet Oslo University Hospital, Norway, and colleagues randomly assigned 457 patients aged at least 80 years with non-STEMI or unstable angina to one of two groups. Both received optimal medical treatment. One group also was transported to a PCI center the day after randomization for an evaluation in the cath lab with subsequent PCI or CABG if necessary.
The primary endpoint was a composite of MI, urgent revascularization, stroke and death during a median follow-up of 1.51 years.
Compared with the conservative group, the invasive group was significantly less likely to experience the primary endpoint (41% vs. 61%; rate ratio = 0.48; 95% CI, 0.37-0.63), the researchers found.
Tegn said the results were driven by differences in the rates of MI (17% vs. 30%; rate ratio = 0.5; 95% CI, 0.33-0.75) and urgent revascularization (2% vs. 11%; rate ratio = 0.19; 95% CI, 0.05-0.52).
The invasive group also had a lower rate of death or MI (35% vs. 48%; rate ratio = 0.54; 95% CI, 0.4-0.73), he said.
There were no differences between the groups in the incidence of bleeding complications, Tegn said, noting that four patients in each group experienced major bleeds.
“Our study demonstrated that an invasive strategy is superior to a conservative strategy in patients over 80 years with non-STEMI or unstable angina,” Tegn said. – by Erik Swain
Reference:
Tegn NK, et al. Late-Breaking Clinical Trials V: TCT@ACC-i2. Presented at: American College of Cardiology Scientific Sessions; March 14-16, 2015; San Diego.
Disclosure: The study was funded by the Norwegian Health Association. Tegn reports no relevant financial disclosures.
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It is interesting that as the population in the U.S. and other countries gets older, we are seeing more older patients coming in with ACS. We’ve looked at this data in California and found that we can reduce the in-hospital mortality rate over the last 15 years more in the elderly than in younger patients. Thus, some of our improvements in lowering mortality in California by 15% have been achieved by lowering the mortality of older patients admitted to the hospital with ACS, so it does not surprise me that focusing on an older group would be valuable.
In this group of individuals with an average age of 84 years, researchers randomized the patients to early invasive therapy, which includes PCI, or conservative therapy. For most 80-year-old people, who we would expect to have a life span of almost 10 years, the question is: Is an invasive procedure going to make a difference in their lifetime and life span? In this study, the individuals who received early invasive therapy had a 47% reduction in their composite event rate compared to those who merely received optimal medical therapy (invasive, 41%; conservative, 61%), which was statistically significant and remarkable.
You might ask: How are we getting away with performing procedures in older individuals? I believe that one advantage of invasive therapy is that we can immediately open the vessel and get cardiac perfusion, and we can reduce the chance of a subsequent MI, death or need for later revascularization in those individuals. The curves separated early and continued to be separate out to 3 years.
For us in the U.S., that means it is now going to be recommended that we take individuals over 80 years and send them for early invasive therapy if they have significant risk factors. The good news is that bleeding side effects — which could be accrued with invasive therapy because we have those individuals on more antiplatelet therapy and more anticoagulation therapy — were not significantly increased. With a minimum of side effects, they were able to achieve a major reduction in the composite outcome of death, MI, stroke and urgent revascularization.