Randomized comparison between the invasive and conservative strategies in comorbid elderly patients with non-ST elevation myocardial infarction

Background: Comorbid elderly patients with non-ST-elevation myocardial infarction (non-STEMI) are underrepresented in randomized trials and undergo fewer cardiac catheterizations according to registries. Our aim was to compare the conservative and invasive strategies in these patients. Methods: Randomized multicenter study, including 106 patients (January 2012-March 2014) with non-STEMI, over 70 years and with comorbidities defined by at least two of the following: peripheral artery disease, cerebral vascular disease, dementia, chronic pulmonary disease, chronic renal failure or anemia. Patients were randomized to invasive (routine coronary angiogram, n = 52) or conservative (coronary angiogram only if recurrent ischemia or heart failure, n = 54) strategy. Medical treatment was identical. The main endpoint was the composite of all-cause mortality, reinfarction and readmission for cardiac cause (postdischarge revascularization or heart failure), at long-term (2.5-year follow-up). Analysis of cumulative event rate (incidence rate ratio = IRR) and time to first event (hazard ratio = HR), were performed. Results: Cardiac catheterization/revascularization rates were 100%/58% in the invasive versus 20%/9% in the conservative arm. There were no differences between groups in the main endpoint (invasive vs conservative: IRR = 0.946, 95% CI 0.466-1.918, p = 0.877) at long-term. The invasive strategy, however, tended to improve 3-month outcomes in terms of mortality (HR = 0.348, 95% CI 0.122-0.991, p = 0.048), and of mortality or ischemic events (reinfarction or postdischarge revascularization) (HR = 0.432, 95% CI 0.190-0.984, p = 0.046). This benefit declined during follow-up. Conclusions: Invasive management did not modify long-term outcome in comorbid elderly patients with non-STEMI. The finding of a tendency towards an improvement in the short-termneeds confirmation in larger studies (clinicaltrials.govNCT1645943). (C) 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.