Revascularisation compared with initial medical therapy for non-ST-elevation acute coronary syndromes in the elderly: a meta-analysis

Gnanenthiran, S.; Kritharides, Leonard; D’Souza, Mario; Lowe, Harry C.; Brieger, David

doi:10.1136/heartjnl-2017-311233

Cited by 26 publications

(24 citation statements)

References 20 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…A meta-analysis that pooled these data, published in 2017, did not find clear evidence that invasive management reduced long-term mortality (OR 0·84, 95% CI 0·66–1·06; p=0·15). 28 Interpretation is difficult because TACTICS-TIMI 18 compared an early invasive with a selective invasive strategy with predischarge ischaemia test, following which 49% of patients underwent coronary catheterisation and 32% had revascularisation. 26 Similarly, the FIR trials, which reported cardiovascular mortality but not all-cause mortality, compared an invasive strategy with a selective invasive strategy, which involved a predischarge ischaemia test, following which nearly half of patients had revascularisation during follow-up.…”

Section: Discussionmentioning

confidence: 99%

Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data

et al. 2020

View full text Add to dashboard Cite

Summary Background Previous trials suggest lower long-term risk of mortality after invasive rather than non-invasive management of patients with non-ST elevation myocardial infarction (NSTEMI), but the trials excluded very elderly patients. We aimed to estimate the effect of invasive versus non-invasive management within 3 days of peak troponin concentration on the survival of patients aged 80 years or older with NSTEMI. Methods Routine clinical data for this study were obtained from five collaborating hospitals hosting NIHR Biomedical Research Centres in the UK (all tertiary centres with emergency departments). Eligible patients were 80 years old or older when they underwent troponin measurements and were diagnosed with NSTEMI between 2010 (2008 for University College Hospital) and 2017. Propensity scores (patients' estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and compared the rate of hospital admissions for heart failure. Findings Of the 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1500 patients had a median age of 86 (IQR 82–89) years of whom (845 [56%] received non-invasive management. During median follow-up of 3·0 (IQR 1·2–4·8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the non-invasive management group (adjusted hazard ratio 0·68, 95% CI 0·55–0·84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48–0·93). Interpretation The survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older. Funding NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative.

show abstract

Section: Discussionmentioning

confidence: 99%

Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data

et al. 2020

View full text Add to dashboard Cite

show abstract

“…Coronary artery disease (CAD) remains a leading cause of morbidity and mortality in older populations. 1,2 Coronary computed tomography angiography (CCTA)-identified non-obstructive and obstructive CAD are both associated with increased major adverse cardiovascular outcomes (MACE) and all-cause mortality. 3 Moreover, atherosclerotic disease burden quantified by either an increasing number of obstructed vessels (single-, double-, triple-vessel, and/or left main) or by the number of coronary segments manifesting atherosclerotic plaque correlate directly with MACE at both medium-and long-term follow-up.…”

Section: Introductionmentioning

confidence: 99%

Long-term prognostic utility of computed tomography coronary angiography in older populations

Gnanenthiran

Naoum

Leipsic

et al. 2019

European Heart Journal - Cardiovascular Imaging

Self Cite

View full text Add to dashboard Cite

Aims The long-term prognostic value of coronary computed tomography angiography (CCTA)-identified coronary artery disease (CAD) has not been evaluated in elderly patients (≥70 years). We compared the ability of coronary CCTA to predict 5-year mortality in older vs. younger populations. Methods and results From the prospective CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, we analysed CCTA results according to age <70 years (n = 7198) vs. ≥70 years (n = 1786). The severity of CAD was classified according to: (i) maximal stenosis degree per vessel: none, non-obstructive (1–49%), or obstructive (>50%); (ii) segment involvement score (SIS): number of segments with plaque. Cox-proportional hazard models assessed the relationship between CCTA findings and time to mortality. At a mean 5.6 ± 1.1 year follow-up, CCTA-identified CAD predicted increased mortality compared with patients with a normal CCTA in both <70 years [non-obstructive hazard ratio (HR) confidence interval (CI): 1.70 (1.19–2.41); one-vessel: 1.65 (1.03–2.67); two-vessel: 2.24 (1.21–4.15); three-vessel/left main: 4.12 (2.27–7.46), P < 0.001] and ≥70 years [non-obstructive: 1.84 (1.15–2.95); one-vessel: HR (CI): 2.28 (1.37–3.81); two-vessel: 2.36 (1.33–4.19); three-vessel/left main: 2.41 (1.33–4.36), P = 0.014]. Similarly, SIS was predictive of mortality in both <70 years [SIS 1–3: 1.57 (1.10–2.24); SIS ≥4: 2.42 (1.65–3.57), P < 0.001] and ≥70 years [SIS 1–3: 1.73 (1.07–2.79); SIS ≥4: 2.45 (1.52–3.93), P < 0.001]. CCTA findings similarly predicted long-term major adverse cardiovascular outcomes (MACE) (all-cause mortality, myocardial infarction, and late revascularization) in both groups compared with patients with no CAD. Conclusion The presence and extent of CAD is a meaningful stratifier of long-term mortality and MACE in patients aged <70 years and ≥70 years old. The presence of obstructive and non-obstructive disease and the burden of atherosclerosis determined by SIS remain important predictors of prognosis in older populations.

show abstract

“…The treatment of coronary artery disease is common in patients over the age of 75 years of age especially within the context of acute coronary syndromes. Careful consideration of the treatment strategy for acute coronary syndromes in this age group is particularly important in view of their increased complexity, complication rate and hospitalisation [6]. In this review, we will briefly discuss the history of percutaneous coronary intervention and then focus on the use of drug-coated balloons giving particular emphasis on their use in de-novo lesions and in the elderly.…”

Section: Introductionmentioning

confidence: 99%

Percutaneous Coronary Intervention in the Elderly: Are Drug-coated Balloons the Future?

Merinopoulos

Gunawardena

Wickramarachchi

et al. 2018

CCR

View full text Add to dashboard Cite

show abstract

Revascularisation compared with initial medical therapy for non-ST-elevation acute coronary syndromes in the elderly: a meta-analysis

Abstract: Routine invasive therapy reduces MI and repeat revascularisation and may reduce mortality at the expense of major bleeding in elderly patients with NSTEACS. Our findings highlight the need for further RCTs to better determine the effect on mortality and contemporary bleeding risk.

Cited by 26 publications

References 20 publications

Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data

Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data

Long-term prognostic utility of computed tomography coronary angiography in older populations

Percutaneous Coronary Intervention in the Elderly: Are Drug-coated Balloons the Future?

Contact Info

Product

Resources

About