Trade-offs With Invasive Strategy in Older Patients With ACS: Meta-analysis

Elderly patients with acute coronary syndrome face trade-offs with an early invasive strategy compared with a more conservative approach, with reduced risks of recurrent events but a heightened tendency for bleeding, a meta-analysis shows.

In pooled data from randomized trials, older patients who were treated invasively had a lower risk of recurrent MI and need for repeat revascularization compared with those treated conservatively, but the invasive strategy was linked to a 60% increased risk of bleeding, Rohin K. Reddy, MBBS (Imperial College London, England), and colleagues report in a study published recently in JAMA Internal Medicine.  

There was no difference in the risk of mortality between the two strategies.

Interventional cardiologist Arnold Seto, MD (Long Beach VA Medical Center, CA), who wasn’t involved in the meta-analysis, said physicians need to take into account more than a person’s age when caring for patients with ACS.

“We do need to use some clinical judgment here,” he told TCTMD. “Even with all the trials that we’ve done, we can’t show a significant benefit of an early invasive strategy for this population. That may change practice because, right now, a lot of people are just locked in [where] a positive troponin [means] you go to the cath lab. It probably serves as a healthy counterpoint to that practice to say: ‘Hey, these patients are at high risk for bleeding and there’s not a clear mortality benefit.’”

There has long been a dearth of data available on the best way to treat older patients with ACS even though they represent an increasing proportion of cases. They’ve typically been excluded from randomized trials and have additional risks of death and complications related to comorbidities. In the context of STEMI, primary PCI has shown a consistent benefit across all ages, but older NSTE ACS patients have historically been treated with medical therapy.

The SENIOR-RITA trial, as reported by TCTMD when presented at the European Society of Cardiology Congress last year, was the first large-scale randomized trial to show that the invasive strategy was safe and beneficial. In that study, an invasive strategy of coronary angiography followed by PCI, if necessary, was associated with a lower risk of nonfatal MI and future revascularization, with no difference seen in harder endpoints, nor any difference in risks of bleeding.

Don’t Be ‘Algorithmic’

The updated meta-analysis includes eight randomized trials with 3,099 patients (mean age 82.6 years; 46% female) presenting with any MI who were treated with coronary angiography plus PCI, if necessary, or conservative treatment with guideline-directed medical therapy. The pooled follow-up was 39.8 months. Only one trial randomized patients with STEMI, comparing the invasive strategy to conservative medical management.

In all patients with ACS, there was no survival advantage with the early invasive approach compared with medical therapy, a finding that was similar when the analysis was restricted to patients with NSTE ACS. The early invasive approach was associated with a 22% lower risk of recurrent MI and a 57% lower risk of coronary revascularization, with the benefits similar in the NSTE ACS patients alone. As noted, bleeding risks were greater with the invasive strategy (relative risk 1.60; 95% CI 1.01-2.53).

Based on their findings, the researchers conclude that “competing risks associated with an early invasive strategy should be weighed in shared therapeutic decision-making for older patients with ACS.”

Seto said that frailty is recognized as an important risk modifier in patients undergoing PCI, pointing out that the National Cardiovascular Disease Registry CathPCI Registry now allows for documentation of frailty. Rather than focus only on age, frailty assessments can help physicians determine a person’s ability to withstand an invasive procedure.

“In a 71-year-old who’s frail, you might want to be more cautious, whereas if it’s a healthy 81-year-old playing pickleball against 50-year-olds, that person might not really be considered elevated risk,” said Seto.

The bottom line, he said, is that physicians need to not be “algorithmic” when confronted with elderly NSTE ACS patients. “You still have to use your judgement regarding the risks and benefits,” he said. “It may help me turn down that 95-year-old patient and say that they’d be better off treated medically. It’s not just ageism.”