Invasive and conservative strategies had similar outcomes in a randomised trial invol­ving patients age 75 years or older with non­-ST-­segment elevation myocardial infarction. 

Optimal management of non-ST-segment elevation myocardial infarction (NSTEMI) in older patients is unknown because they are under-represented in clinical trials. Investigators with the SENIOR-RITA trial have now compared conservative management (best available medical therapy alone) with an invasive strategy (coronary angiography and, as appropriate, revascularisation; plus medical therapy) in a randomised trial involving 1518 patients aged 75 years or older (mean age, 82 years; 45% women; 32% frail) with NSTEMI at 48 sites in the UK. More than 80% of patients in each group were on dual antiplatelet therapy; more than 10% were on triple therapy (dual antiplatelet plus anticoagulation).

Of the invasively managed group, roughly 90% had a successful radial-artery approach, and half underwent coronary revascularisation. Of the conservatively managed group, 24% eventually underwent coronary angiography, more than half of whom proceeded to revascularisation.

By a median follow up of 4.1 years, the two groups did not differ significantly in the composite end point of cardiovascular death or nonfatal MI (roughly 26% incidence in each group), although nonfatal MI was less common with the invasive than the conservative strategy (11.7% vs 15.0%; hazard ratio, 0.75; 95% confidence interval, 0.57 to 0.99). The two groups did not differ significantly in their incidences of stroke or major bleeding. 

Comment: These findings support what many of us in invasive cardiology have long believed and practiced (without hard data) in this patient population: patients’ wishes and goals of care are what matter. In my opinion, the most important message from the data is that patients do not face a mortality ‘penalty’ for choosing between invasive and noninvasive approaches.

Shea E. Hogan, MD, MSCS, FACC, FSCAI, FSVM, Interventional Cardiologist, Denver Health; Associate Professor of Clinical Medicine, University of Colorado School of Medicine; Clinician-Scientist, CPC Clinical Research, Denver, USA.

Kunadian V, et al. Invasive treatment strategy for older patients with myocardial infarction. N Engl J Med 2024 Sep 1; e­pub (https://doi.org/10.1056/NEJMoa2407791).

This summary is taken from the following Journal Watch titles: Cardiology, General Medicine, Ambulatory Medicine.