Invasive Strategy In Elderly Patients Research Articles

Conservative versus Invasive Strategy in Elderly Patients with Non-ST-Elevation Myocardial Infarction: Insights from the International POPular Age Registry.

This registry assessed the impact of conservative and invasive strategies on major adverse clinical events (MACE) in elderly patients with non-ST-elevation myocardial infarction (NSTEMI). Patients aged ≥75 years with NSTEMI were prospectively registered from European centers and followed up for one year. Outcomes were compared between conservative and invasive groups in the overall population and a propensity score-matched (PSM) cohort. MACE included cardiovascular death, acute coronary syndrome, and stroke. The study included 1190 patients (median age 80 years, 43% female). CAG was performed in 67% (N = 798), with two-thirds undergoing revascularization. Conservatively treated patients had higher baseline risk. After propensity score matching, 319 patient pairs were successfully matched. MACE occurred more frequently in the conservative group (total population 20% vs. 12%, adjHR 0.53, 95% CI 0.37-0.77, p = 0.001), remaining significant in the PSM cohort (18% vs. 12%, adjHR 0.50, 95% CI 0.31-0.81, p = 0.004). In conclusion, an early invasive strategy was associated with benefits over conservative management in elderly patients with NSTEMI. Risk factors associated with ischemia and bleeding should guide strategy selection rather than solely relying on age.

Management and outcome of non-ST-elevation acute coronary syndromes in the elderly admitted to spoke hospitals with no cath-lab facility

Abstract Background Current guidelines recommend an early invasive strategy in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, the role of an invasive strategy in elderly patients remains controversial and may be difficult to achieve in spoke hospitals with no cath-lab facility. Purpose We aimed to analyze characteristics and outcomes of patients ≥80 years with NSTE-ACS admitted to spoke hospitals. Methods Observational retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals, where a service strategy (same-day transfer between spoke hospital and hub center with a cath-lab facility to perform coronary angiography) was available. Results From 2013 to 2017, 639 patients were admitted for NSTE-ACS in a spoke hospital of our provincial cardiology network; of these, 181 (28%) were ≥80 years (median 84, IQR 82–89). In the elderly conservative strategy was chosen in 76 patients (42%). When the invasive strategy was chosen, 104 patients (93%) were managed with a Service strategy with no major adverse event observed during the back transfer from the invasive center to the referring spoke center, whereas the rest of the patients (8, 7%) were transferred from the spoke hospital to the hub center and completed their hospital stay without returning to the spoke center. Of patients initially managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 11 (10%) and the patients remained in the hub center. The median time to access to cath-lab was 50 hours (IQR 25–87), with 73 patients (70%) reaching the invasive procedure <72 h from the hospital admission and 23 (22%) <24 h. Conservative strategy was associated with older age, known previous CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD, and atrial fibrillation (all p<0.03; Table). At 1-year follow-up, the overall survival was significantly higher in patients treated with invasive strategy compared to patients managed conservatively (94%±2 vs. 54%±6, p<0.001; HR: 10.4 [4.7–27.5] p<0.001; Figure), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0–4.0]; p<0.001). Conclusion An invasive strategy may confer a survival benefits in the elderly with NSTE-ACS. When the invasive strategy is chosen, the same-day transfer between spoke hospital and hub center with the cath-lab facility (service strategy) is safe and granted the access to cath-lab in a timely fashion even in the elderly. Funding Acknowledgement Type of funding sources: None. Table 1Figure 1

Invasive strategy in elderly patients with acute coronary syndrome in 2018: close to the truth?

Elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes (ACS). The optimal management of ACS in these patients is still a challenge due to their clinical peculiarities and the paucity of specific data, and they have been traditionally managed more conservatively mainly based on subjective criteria. In ST-segment elevation acute myocardial infarction urgent reperfusion is the standard of care and there is no upper age limit. In non-ST segment elevation acute myocardial infarction evidence is controversial, incomplete and mainly focused on chronological age. While a strict conservative strategy should be avoided, routine invasive strategy may reduce the occurrence of myocardial infarction and need for revascularization at follow-up with no established benefit in terms of mortality. Clinical characteristics associated with aging, such as comorbidities and frailty, further discriminate patient's risk beyond age. Evidence is scarce, but it suggests that these features may modulate the benefit of invasive strategy in this population. Ongoing trials should clarify the optimal management of ACS based on these parameters.

GW29-e0803 The prognostic analysis of the early invasive strategy in elderly patients with acute Non-ST-Segment elevation myocardial infarction

This study aims to evaluate the prognosis of the early invasive strategy in elder patients with acute Non-ST-Segment elevation myocardial infarction (NSTEMI). We retrospectively analyzed elderly acute NSTEMI patients who were hospitalized in the third Affiliated Hospital of Sun Yat-sen University

Rationale and design of the DEAR-OLD trial: Randomized evaluation of routinely Deferred versus EARly invasive strategy in elderly patients of 75 years or OLDer with non–ST-elevation myocardial infarction

Comparing with conservative strategy, early invasive approach has been shown to be beneficial for initially stabilized patients with non-ST-elevation myocardial infarction (NSTEMI). However, concerns of increased risk of bleeding and other complications associated with early revascularization in patients aged ≥75 years persist. A routinely deferred invasive strategy aiming to facilitate revascularization after stabilizing the culprit lesion predominates across China. The aim was to compare efficacy and safety of deferred invasive strategy versus guideline-recommended early invasive strategy in initially stabilized Chinese patients aged ≥75 years with NSTEMI. Twenty qualified centers from 10 different provinces throughout mainland China will contribute to the study. Eligible patients will be central randomized to a routine deferred invasive approach or an early invasive approach (coronary angiography >72 hours or <24 hours of admission and appropriate revascularization). Patients meeting the inclusion criteria but not randomized for any reason will be registered. The primary end point of the present study is a composite of all-cause mortality, nonlethal (re) MI, ischemic stroke, and urgent revascularization at 1 year. Noninferiority design is used, and the inferiority margin was set to be 5%. The goal is to enroll 696 patients with expected primary end point rates of 30%, 2-tailed α of .05, power of 80%, and dropout rate of 5%. The DEAR-OLD trial is a prospective, nationwide, multicenter, noninferiority-designed, open-label randomized clinical trial evaluating efficacy and safety of routinely deferred invasive strategy compared with early invasive strategy in Chinese elderly patients with NSTEMI.

Determinants of invasive strategy in elderly patients with non-ST elevation myocardial infarction.

BackgroundKnowledge gaps across literature prevent current guidelines from providing the profile of elderly patients most likely to derive benefit from invasive strategy (IS) in non ST-elevation myocardial infarction (NSTEMI). Furthermore, the benefit of IS in a real-world elderly population with NSTEMI remains unclear. The aims of this study were to determine factors that lead the cardiologist to opt for an IS in elderly patients with NSTEMI, and to assess the impact of IS on the 6-month all-cause mortality.MethodsThis multicenter prospective study enrolled all consecutive patients aged ≥ 75 years old who presented a NSTEMI and were hospitalized in cardiology intensive care unit between February 2014 and February 2015. Patients were compared on the basis of reperfusion strategy (invasive or conservative) and living status at six months, in order to determine multivariate predictors of the realization of an IS and multivariate predictors of 6-month mortality.ResultsA total of 141 patients were included; 87 (62%) underwent an IS. The strongest independent determinants of IS were younger age [odds ratio (OR): 0.85, 95%-confidence interval (CI): 0.78–0.92; P < 0.001) and lower “Cumulative Illness Rating Scale-Geriatric” number of categories score (OR: 0.83, 95%CI: 0.73–0.95; P = 0.002). IS was not significantly associated with 6-month survival (OR: 0.80, 95%CI: 0.27–2.38; P = 0.69).ConclusionsIn real-world elderly patients with NSTEMI, younger patients with fewer comorbidities profited more often from an IS. However, IS did not modify 6-month all-cause mortality.

0464: Impact of invasive strategy in elderly patients referred for acute coronary syndrome

Limited data are available in elderly patients admitted for acute coronary syndromes (ACS). The purpose of this study is to assess the beneficial impact of aggressive treatment strategy (i.e. coronary angiogram and revascularization) on outcome in elderly patients . Among 1702 patients admitted for ACS , 294 patients were ≥80 years old. ACS was defined as chest pain associated with either troponin rise or new change in ST segment or T wave. Patients with STEMI were excluded and 235 patients (85±3 years old, 125 men) were analyzed. We compared outcome (death and emergency readmission) according to treatment strategy (conservative or invasive) Coronary angiography was performed in 146 patients while 88 received medical treatment alone. Patients with angiography performed were younger (84.5±3.2 years vs. 85.6±3.9 years) but had similar event risk (GRACE score 174±26 vs. 179±33). During follow up (median=498 days), one year mortality and emergency readmission was similar regardless the decision to perform angiogram (41.2% vs. 43.6%, p=0.7) but in hospital stay was longer when angiogram was performed (4.1±3.7 vs. 2.9±2.8, p=0.01). Among the 146 patients who underwent angiography, revascularization was performed in 98. Age did not influence revascularization but Grace score did (177±26 vs. 167±30). Importantly, only patients with Left main (LM) or proximal LAD disease benefited from revascularization (1-year free event survival 26% vs. 79%, p=0.0003) whereas patients without did not (39% vs. 35%, p=0.7). Kaplan Meier analysis of outcome during follow up confirmed that patients with non revascularized LM or proximal LAD disease had worth outcome (LogRank p=0.009) Invasive management of ACS in elderly patients improves survival in patients with LM or proximal LAD disease. In other patients, it only prolongs in-hospital stay. Upstream stratification may be useful to identify patients with suspected LM or proximal LAD disease.

Effects of age on long-term outcomes after a routine invasive or selective invasive strategy in patients presenting with non-ST segment elevation acute coronary syndromes: a collaborative analysis of individual data from the FRISC II - ICTUS - RITA-3 (FIR) trials

ObjectiveTo perform a patient-pooled analysis of a routine invasive versus a selective invasive strategy in elderly patients with non-ST segment elevation acute coronary syndrome.MethodsA meta-analysis was performed of patient-pooled data...

Early invasive strategy in elderly patients with non-ST-elevation acute coronary syndromes

The clinical impact of an early invasive strategy (EIS) on elderly patients with acute coronary syndromes (ACSs) has yet to be completely defined because of the poor enrolment of elderly patients in randomized trials in this setting. The reluctance to treat elderly ACS patients is mainly due to the higher risk profile of these patients when percutaneous or surgical revascularization is planned. However, recent clinical data from different centres strongly support the use of an EIS in the elderly, showing a significantly larger absolute reduction in 30-day major adverse clinical events in elderly patients than that in younger patients, and prompt the need for dedicated randomized trials.