NEW YORK (Reuters Health) – An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction
(NSTEMI) or unstable angina, according to the After Eighty clinical trial.
“Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities,” Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. “These factors may reduce the benefits and increase the risk of complications from invasive treatment.”
Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.
Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a
conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.
The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.
In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.
During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).
Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.
Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).
“The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina,” Dr.Bendz and Dr. Tegn said. “However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference.”
Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, “The After-80 study now provides the direct
evidence we needed to support this ‘early invasive’ approach. Given how difficult it is to recruit very elderly patients to clinical studies – and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 – the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many ‘very old’ patients admitted to our cardiology and general medicine wards with ACS.”
“In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not
enrolled,” he reiterated. “There would have been many reasons why so many patients were excluded, but it does emphasize that the study’s findings won’t apply to everyone over the age of 80 who presents with ACS.”
“As always, the decision making process needs to be individually tailored,” Dr. Psaltis said. “The patient’s pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account.”