Early Aggressive Versus Initially Conservative Treatment in Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndrome

• DOI: 10.1016/j.jcin.2012.06.008
• Publication Date: 2012-09-18T02:16:16Z
• Authors: Stefano Savonitto; Claudio Cavallini; A. Sonia Petronio; Ernesto Murena; Roberto Antonicelli; Alice Sacco; Giuseppe Steffenino; Francesco Bonechi; Ernesto Mossuti; Antonio Manari; Salvatore Tolaro; Anna Toso; Alessandro Daniotti; Federico Piscione; Nuccia Morici; Bruno M. Cesana; M. Cristina Jori; Stefano De Servi
• Keywords: Male; Myocardial Infarction; 610; Kaplan-Meier Estimate; Postoperative Hemorrhage; Coronary Angiography; elderly; Patient Readmission; Risk Assessment; acute coronary syndrome; 03 medical and health sciences; Percutaneous Coronary Intervention; 0302 clinical medicine; Risk Factors; Humans; Acute Coronary Syndrome; Coronary Artery Bypass; Aged; Proportional Hazards Models; acute coronary syndrome; angioplasty; elderly; revascularization; treatment; Aged, 80 and over; treatment; Age Factors; angioplasty; Cardiovascular Agents; 3. Good health; Italy; revascularization; Female; Cardiology and Cardiovascular Medicine; Biomarkers

This study sought to determine the risk versus benefit ratio of an early aggressive (EA) approach in elderly patients with non-ST-segment elevation acute coronary syndromes (NSTEACS).Elderly patients have been scarcely represented in trials comparing treatment strategies in NSTEACS.A total of 313 patients ≥ 75 years of age (mean 82 years) with NSTEACS within 48 h from qualifying symptoms were randomly allocated to an EA strategy (coronary angiography and, when indicated, revascularization within 72 h) or an initially conservative (IC) strategy (angiography and revascularization only for recurrent ischemia). The primary endpoint was the composite of death, myocardial infarction, disabling stroke, and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year.During admission, 88% of the patients in the EA group underwent angiography (55% revascularization), compared with 29% (23% revascularization) in the IC group. The primary outcome occurred in 43 patients (27.9%) in the EA group and 55 (34.6%) in the IC group (hazard ratio [HR]: 0.80; 95% confidence interval [CI]: 0.53 to 1.19; p = 0.26). The rates of mortality (HR: 0.87; 95% CI: 0.49 to 1.56), myocardial infarction (HR: 0.67; 95% CI: 0.33 to 1.36), and repeat hospital stay (HR: 0.81; 95% CI: 0.45 to 1.46) did not differ between groups. The primary endpoint was significantly reduced in patients with elevated troponin on admission (HR: 0.43; 95% CI: 0.23 to 0.80), but not in those with normal troponin (HR: 1.67; 95% CI: 0.75 to 3.70; p for interaction = 0.03).The present study does not allow a definite conclusion about the benefit of an EA approach when applied systematically among elderly patients with NSTEACS. The finding of a significant interaction for the treatment effect according to troponin status at baseline should be confirmed in a larger size trial. (Italian Elderly ACS Study; NCT00510185).