Abstract
Objective
To evaluate outcomes of routine invasive strategy (RIS) compared with selective invasive
strategy (SIS) in elderly patients older than 75 years with non-ST-segment elevation
acute coronary syndrome (NSTE-ACS).
Methods
We systematically searched databases for randomized controlled trials (RCTs) between
January 1, 1990, and October 1, 2016, comparing RIS with SIS for elderly patients
(age>75 years) with NSTE-ACS. Random effects meta-analysis was conducted to estimate
odds ratio (OR) with 95% CIs for composite of death or myocardial infarction (MI),
and individual end points of all-cause death, cardiovascular (CV) death, MI, revascularization,
and major bleeding.
Results
A total of 6 RCTs with 1887 patients were included in the final analysis. Compared
with an SIS, RIS was associated with significantly decreased risk of the composite
end point of death or MI (OR, 0.65; 95% CI, 0.51-0.83). Similarly, RIS led to a significant
reduction in the risk of MI (OR, 0.51; 95% CI, 0.40-0.66) and need for revascularization
(OR, 0.31; 95% CI, 0.11-0.91) compared with SIS. There were no significant differences
between RIS and SIS in terms of all-cause death (OR, 0.85; 95% CI, 0.63-1.20), CV
death (OR, 0.84; 95% CI, 0.61-1.15), and major bleeding (OR, 1.96; 95% CI, 0.97-3.97).
Conclusion
In elderly patients older than 75 years with NSTE-ACS, RIS is superior to SIS for
the composite end point (death or MI), primarily driven by reduced risk of MI.
Abbreviations and Acronyms:
CABG (coronary artery bypass grafting), CV (cardiovascular), MI (myocardial infarction), NSTE-ACS (non-ST-segment elevation acute coronary syndrome), OR (odds ratio), PCI (percutaneous coronary intervention), RCT (randomized controlled trial), RIS (routine invasive strategy), SIS (selective invasive strategy)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Mayo Clinic ProceedingsAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Heart disease and stroke statistics—2013 update: a report from the American Heart Association.Circulation. 2013; 127: e6-e245
- 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 64: e139-e228
- Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. FRISC II Investigators. Fast Revascularisation during Instability in Coronary artery disease.Lancet. 2000; 356: 9-16
- Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.N Engl J Med. 2001; 344: 1879-1887
- Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized Intervention Trial of unstable Angina.Lancet. 2002; 360: 743-751
- 5-year outcomes in the FRISC-II randomised trial of an invasive versus a non-invasive strategy in non-ST-elevation acute coronary syndrome: a follow-up study.Lancet. 2006; 368: 998-1004
- 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial.Lancet. 2005; 366: 914-920
- Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: a meta-analysis of individual patient data.Am Coll Cardiol. 2010; 55: 2435-2445
- Acute coronary care in the elderly, part I: non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology.Circulation. 2007; 115: 2549-2569
- Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial.JACC Cardiovasc Interv. 2012; 5: 906-916
- Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial.Lancet. 2016; 387: 1057-1065
- Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation.BMJ. 2015; 350: g7647
- Cochrane handbook for systematic reviews of interventions.(Version 5.1.0 [updated March 2011]. The Cochrane Collaboration; 2011)
- The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes.Ann Intern Med. 2004; 141: 186-195
- Effects of age on long-term outcomes after a routine invasive or selective invasive strategy in patients presenting with non-ST segment elevation acute coronary syndromes: a collaborative analysis of individual data from the FRISC II - ICTUS - RITA-3 (FIR) trials.Heart. 2012; 98: 207-213
- An overview of PCI in the very elderly.J Geriatr Cardiol. 2015; 12: 174-184
- Community surveillance event rates.(Atherosclerosis Risk in Communities (ARIC) study) (Accessed April 16, 2017)
- Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era.Cochrane Database Syst Rev. 2010; : CD004815
- One-year results of the Thrombolysis in Myocardial Infarction (TIMI) IIIB clinical trial: a randomized comparison of tissue-type plasminogen activator versus placebo and early invasive versus early conservative strategies in unstable angina and non-Q wave myocardial infarction.J Am Coll Cardiol. 1995; 26: 1643-1650
- Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators.N Engl J Med. 1998; 338: 1785-1792
- Effect of an invasive strategy on outcome in patients ≥75 years of age with non-ST-elevation acute coronary syndrome.Am J Cardiol. 2015; 115: 576-580
- Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials.JAMA. 2005; 293: 2908-2917
- Temporal trends in and factors associated with bleeding complications among patients undergoing percutaneous coronary intervention: a report from the National Cardiovascular Data CathPCI Registry.J Am Coll Cardiol. 2012; 59: 1861-1869
- Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE).Am Heart J. 2005; 149: 67-73
Article Info
Publication History
Published online: February 10, 2018
Footnotes
Potential Competing Interests: The authors report no competing interests.
Identification
Copyright
© 2017 Mayo Foundation for Medical Education and Research
