Invasive management in elderly patients with non-ST elevation myocardial infarction is beneficial regardless of frailty status

Abstract

Introduction Elderly patients are underrepresented in clinical trials evaluating the management of non-ST elevation myocardial infarction (NSTEMI) patients. Moreover, frailty status is often not reported in these trials. Purpose To evaluate the association of invasive management with outcome among elderly (≥80) patients presenting with NSTEMI by frailty status. Methods Retrospective cohort of consecutive elderly patients who were hospitalized with NSTEMI as a primary clinical diagnosis between 2008 to 2019. Primary outcome was all-cause mortality. Frailty status was estimated as a continuous variable as well as categorized to low, medium, and high. Cox regression models were applied with stratification by frailty status. Additional sensitivity analyses were conducted including propensity score matching (PSM) and inverse probability treatment weighting (IPTW) models. Results Study population included 2,317 patients with median age of 86 years (IQR 83–90) of whom 1,243 (54%) were men. Patients who were managed invasively (n=581 [25%]) were less likely to be frail (7% vs. 44%, p<.001). During the follow up (median of 19 months, [IQR 4–41]), 1,599 (69%) patients died. Kaplan Meier survival curves (Figure 1) show that the cumulative probability of death at 19 months was 50% among patients who were managed conservatively compared with 21% among invasively managed patients (p Log rank <.001). In the multivariable Cox model, invasive approach was associated with a significant 39% decrease in the risk of death (95% CI 0.53–0.71). The benefit of invasive approach was consistent among low, medium, and high frailty subgroups with adjusted HRs of 0.74 [0.58–0.93], 0.65 [0.50–0.85] and 0.52 [0.34–0.78], respectively; p for interaction NS). Results were consistent with PSM and IPTW analyses (HR of 0.6 [0.50–0.71] and 0.67 [0.55–0.82], respectively). Additional sensitivity analysis addressing potential immortal time bias and residual confounding yielded similar results. Conclusions Invasive approach is associated with improved survival among elderly patients with NSTEMI irrespective of frailty status. Our results support and extend recent ESC recommendations for the management of elderly patients with NSTEMI FUNDunding Acknowledgement Type of funding sources: None. Figure 1

Comparing health outcomes between coronary interventions in frail patients aged 75 years or older with acute coronary syndrome: a systematic review

“…Fishman et al [ 24 ] did not clarify the method for assessing frailty in their study. Each of the remaining studies included in this review used a different scale for assessing frailty.…”

“…Forty-five articles were excluded as they either included the wrong population ( n = 16), did not report comparative outcomes ( n = 28), or were conference abstracts superseded by a journal article ( n = 1) [ 15 , 16 ]. Nine studies listed in Table 2 met all eligibility criteria [ 15 , 17 – 24 ].…”

“…However, all ACS subtypes were represented across the included studies. STEMI patients were included in six studies [ 15 , 17 , 20 – 23 ], NSTEMI patients in all nine studies [ 15 , 17 – 24 ], and UA in four studies [ 18 , 19 , 22 , 23 ].…”

“…The studies used four different approaches to defining treatment and control groups. Alonso et al [ 15 ], Dodson et al [ 20 ], Llao et al [ 19 ], and Fishman et al [ 24 ] compared treatment differences between an invasive treatment and conservative treatment. Di Bari et al [ 17 ], Nunez et al [ 18 ], Wong, Lee, & El-Jack [ 23 ], and Damluji et al [ 21 ] compared outcomes between patients treated with PCI and patients who were not.…”

“…The primary outcome measures used in the remaining studies are generally accepted as measures of efficacy or effectiveness [ 6 , 13 , 36 ]. These included: in-hospital mortality (Kwok et al [ 22 ], Damluji et al [ 21 ]; medium-term (6-month) Death, MI or unplanned revascularization (Llao et al [ 19 ]); long-term (≥ 1 year) mortality (Di Bari et al [ 17 ]), Wong, Lee and El-Jack [ 23 ], and Fishman et al [ 24 ]); long-term death or MI (Alonso et al [ 15 ]); and long-term all-cause readmission (Nunez et al [ 18 ]).…”