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Title: Invasive versus Conservative Management in Patients ≥85 years presenting with Non-ST Elevation Myocardial Infarction.
Austin Authors: Kunniardy, Phelia;Koshy, Anoop N ;Meehan, Georgie;Murphy, Alexandra C ;Ramchand, Jay ;Clark, David J ;Farouque, Omar ;Yudi, Matias B 
Affiliation: Cardiology
Heart and Vascular Institute, Cleveland Clinic Miller Family Heart and Vascular Institute, Cleveland, Ohio, USA
Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
Issue Date: 1-Mar-2021 2021-03-01
Publication information: Internal Medicine Journal 2021; online first: 1 March
Abstract: Guidelines recommend early coronary angiography (CA) in patients with non-ST-elevation myocardial infarction (NSTEMI), irrespective of age. However, elderly patients are less likely to be treated according to these guidelines due to their perceived high risk and medical comorbidities. Whether an invasive strategy is associated with improved survival in patients aged ≥85 years remains uncertain due to their exclusion from randomised trials. Consecutive patients aged ≥85 years presenting to a tertiary centre with NSTEMI between 2008-18 were included in this retrospective cohort study. Patients were stratified based on whether they underwent invasive management with CA with a view to revascularisation versus conservative management. The primary outcome was long-term mortality. Of 7,591 patients with NSTEMI, 1052 patients ≥85years were included. 99(9.4%) patients underwent CA. Those undergoing CA were more likely to be younger, male, live independently, without mobility or cognitive issues (all p<0.01). Overall, 495(47%) patients died during a mean follow-up of 1.3±1 year. On Cox regression, after adjusting for age, pre-morbid functional status, cognition and cardiovascular risk factors, invasive management was the strongest predictor for survival (HR 0.47; 95%CI 0.26-0.85; p=0.01). Invasive management was associated with a trend to increased risk of in-hospital bleeding (6.1% vs 2.6%, p=0.054) with no significant difference in stroke (2.0% vs 3.8%, p=0.37). In patients aged ≥85 years who presented with NSTEMI, invasive management was associated with improved survival without significant differences in bleeding or stroke. A randomised controlled study assessing the efficacy and safety of invasive management in very elderly patients with NSTEMI is warranted. This article is protected by copyright. All rights reserved.
DOI: 10.1111/imj.15258
ORCID: 0000-0002-3297-311X
Journal: Internal Medicine Journal
PubMed URL: 33647172
Type: Journal Article
Subjects: Elderly
Non-ST-elevation myocardial infarction (NSTEMI)
conservative management
invasive management
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