An early invasive approach to NSTEMI in the elderly: A double‐edged sword?

Abstract

Urgent and timely revascularization is a wellestablished cornerstone of therapy in the treatment of ST elevation myocardial infarction (STEMI). However, guidelines directing therapy in non-ST segment elevation myocardial infarction (NSTEMI) are not as definitive. These guidelines recommend two treatment pathways: an early invasive strategy (EIS) and an initial conservative strategy.The EIS directs patients toward invasive diagnostic evaluation often prior to noninvasive testing, without failing medical therapy, and on a more expeditious time frame (<24 h from presentation). This strategy confers several advantages besides risk stratification alone. Percutaneous intervention of the culprit lesion reduces the need for chronic anti-anginal therapy and rehospitalizations. In addition, patients identified as having multivessel disease would gain the added mortality benefit from referral for coronary artery bypass graft surgery early.The initial conservative strategy recommends an invasive approach for those who fail medical therapy or if there is objective evidence of active ischemia on noninvasive testing. This strategy has the advantage of avoiding the risks associated with an invasive procedure. When this strategy is chosen, often noninvasive evaluation is required to assess for significant ischemia and to identify left ventricular dysfunction. Deciding which strategy to take can be done based on riskstratifying patients using risk calculators such as thrombolysis in myocardial infarction (MI) or the global registry of acute coronary events calculator [1].In the United States, among people who died of ischemic heart disease, 83% were older than 65 years. Moreover, even though people older than 75 years only account for 6% of the US population, they represent 60% of MI-related deaths [2]. Increasing age is one of the major predictors of poorer outcomes in NSTEMI. However, despite the fact that the guidelines recommend therapeutic interventions based on risk rather than age, there appears to be widespread reluctance to use an invasive strategy in a uniform manner in the elderly population. This is likely in part, due to the fact that the elderly population is under-represented or excluded in acute coronary syndrome (ACS) clinical trials; therefore, there is limited evidence guiding treatment in this population.In this issue of Catheterization and Cardiovascular Interventions, Angeli et al.[3] present a meta-analysis of nine randomized clinical trials (RCTs) involving 9,400 patients comparing the benefit of an EIS to a selectively invasive strategy (SIS). The primary composite endpoint of MI and all-cause death was 16% in the EIS group and 18.3% in the SIS group (OR: 0.85, 95% CI: 0.76-0.95). In addition, the reduction in rehospitalization and recurrent MI was greater in the older population (>65 years) as compared to younger study populations. Moreover, the benefit was seen in both male and female subgroups.This article adds to the evidence suggesting the benefits of EIS that has been accumulating since 1999. Evidenc...

Temporal Pattern of CABG and PCI after Non-ST Elevation Myocardial Infarction Among Elderly Patients from NHDS.

“…Angeli et al compared the benefit of early invasive to selectively invasive strategy. The endpoint of developing an MI or occurrence of death was found to be lower in early invasive strategy and the benefit was seen to be equal in both sexes [2]. The benefits from an early invasive strategy comes mainly as a result of improvement in medical therapy and antiplatelet strategies which have brought down the increased risk of bleeding.…”

“…This again points to careful assessment of risk versus benefits by the physician based on individual patient's comorbidities, previous complications, current medications, and also patient's wishes. The age cut-off should never be the sole criterion [2].…”

“…In most situations, UA/NSTEMI are caused by coronary artery disease (CAD) leading to an increased risk of cardiac death and myocardial infarction [1]. Prompt revascularization is the therapy of choice in STEMI, however clear guidelines are lacking to address NSTEMI [2]. As per the American College of Cardiology/American Heart Association guidelines, two treatment pathways have emerged for treating patients with UA/NSTEMI.…”