Early Invasive Strategy Linked to Worse QoL in Elderly NSTEMI Patients
Analysis of two large acute MI studies suggests the strategy’s benefits narrow with age, providing the most to younger patients.
Gains in health-related quality of life (QoL) may be minimal and health status may even decline when elderly NSTEMI patients are treated with an initial invasive strategy, according to results from an analysis of two multicenter registries.
“We found that initial invasive treatment is associated with a small benefit in health status on follow-up, mainly accounted for by younger patients, compared to conservative management. However, it was below the 5-point threshold of clinical significance,” lead study author Krishna K. Patel, MD (Saint Luke’s Mid America Heart Institute, Kansas City, MO), said in an email.
“While there was no significant interaction of treatment with age for disease-specific health status (Seattle Angina Questionnaire), patients 85 years or older appeared to derive no health status benefit with routine invasive management with a trend towards harm,” she added. In fact, Patel noted, the older patients also had significantly lower physical composite scores on the Short Form-12 Health survey with invasive versus conservative management, indicating poor health status in general.
Risk-Treatment Paradox Identified
Patel and colleagues’ study, published online earlier this month in the American Journal of Cardiology, examined data from the PREMIER and TRIUMPH registries, both of which enrolled acute MI patients at sites in the United States. Of 3,559 NSTEMI patients in the two cohorts (mean age of 61 years), 69% were treated with an initial invasive management (50.3% within the first 24 hours) and the remainder with ischemia-guided treatment.
Only 44.2% of patients aged 85 years or older received invasive management compared with 72.4% of those under age 65. According to Patel, those findings confirm a “risk-treatment paradox” in NSTEMI, since older patients typically had greater comorbidities and higher risk.
For the group as a whole, QoL benefits of invasive management were greatest early on and tended to decline over the course of the year. In sensitivity analyses, measures of angina-specific QoL, angina-specific health status, and general physical limitation all were worse at 1 year in patients over age 85 when invasive management was the initial strategy, regardless of timing (ie, within the first 24 hours or later).
To TCTMD, Patel said more research is needed to tease out who among the oldest old may benefit in terms of health status and quality of life from routine invasive management and who may not. The study cohort only had 120 patients in that age range, limiting the ability to make firm conclusions about the benefit, or lack thereof, of invasive management in this group, she added.
“Our study is the first one to our knowledge which raises the question that older patients might not derive a health status benefit and might potentially have poorer health status with invasive management, something we strongly believe should be the subject of further investigation,” Patel noted.
She and her team suggest that the findings have implications for patient-centered decision-making in treatment selection, particularly when it comes to balancing potential risks and benefits; this trade-off is more complicated in older patients who have greater periprocedural risks than younger patients. Current guidelines recommend routine invasive management in high-risk patients, a practice that Patel and colleagues point out could be applicable to nearly all older patients. They suggest that “understanding these trade-offs can help patients make an informed decision about the treatment they receive based on their individual preferences.”
Patel KK, Arnold SV, Jones PG, et al. Relation of age and health-related quality of life to invasive versus ischemia-guided management of patients with non-ST elevation myocardial infarction. Am J Cardiol. 2018;Epub ahead of print.
- Patel reports no relevant conflicts of interest.