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

  • Author Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Juan Sanchis
    Correspondence
    Corresponding author at: Department of Cardiology, Hospital Clínico Universitario, Blasco Ibáñez 17, 46010 Valencia, Spain. Tel.: +34 963862679; fax: +34 96382658.
    Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Affiliations
    Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
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  • Author Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Eduardo Núñez
    Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Affiliations
    Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
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  • José Antonio Barrabés
    Affiliations
    Department of Cardiology, Hospital Universitari Vall d'Hebrón, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
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  • Francisco Marín
    Affiliations
    Department of Cardiology, Hospital Virgen Arrixaca, Murcia, Spain
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  • Luciano Consuegra-Sánchez
    Affiliations
    Department of Cardiology, Hospital Santa Lucía, Cartagena, Spain
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  • Author Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Silvia Ventura
    Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Affiliations
    Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
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  • Author Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Ernesto Valero
    Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Affiliations
    Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
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  • Mercè Roqué
    Affiliations
    Department of Cardiology, Hospital Clinic, Barcelona, Spain
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  • Antoni Bayés-Genís
    Affiliations
    Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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  • Bruno García del Blanco
    Affiliations
    Department of Cardiology, Hospital Universitari Vall d'Hebrón, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
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  • Irene Dégano
    Affiliations
    IMIM (Hospital del Mar Medical Research Institute), Universitat Autonoma de Barcelona, Barcelona, Spain
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  • Author Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Julio Núñez
    Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.
    Affiliations
    Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
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  • Author Footnotes
    1 This author takes responsibility and freedom from bias of the data presented and their discussed interpretation.

      Highlights

      • Invasive strategy did not improve long-term outcome in non-STEMI with comorbidities.
      • A tendency towards a better outcome in the short-term was observed.
      • Comorbidities should not dissuade the invasive management in non-STEMI.
      • The fact that mid and long term outcomes remained unmodified must be kept in mind.

      Abstract

      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-term needs confirmation in larger studies (clinicaltrials.govNCT1645943).

      Graphical abstract

      Keywords

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