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Canadian Journal of Cardiology

An Invasive vs a Conservative Approach in Elderly Patients with Non–ST-Segment Elevation Myocardial Infarction: Systematic Review and Meta-Analysis

  • Avadhesh Saraswat
    Affiliations
    Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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  • Atifur Rahman
    Affiliations
    Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia

    Department of Medicine, Griffith University, Gold Coast, Queensland, Australia
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  • Kuljit Singh
    Correspondence
    Corresponding author: Kuljit Singh, MBBS, PhD, FRACP, Department of Cardiology, Griffith University, Gold Coast University Hospital, 1 Hospital Blvd, Southport, Queensland, Australia. Tel.: +61 5687 0000; fax: +61 5687 4597.
    Affiliations
    Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia

    Department of Medicine, Griffith University, Gold Coast, Queensland, Australia

    Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Published:December 04, 2017DOI:https://doi.org/10.1016/j.cjca.2017.11.020

      Abstract

      Background

      Elderly (≥ 75 years) patients form a large sub-group of non–ST-segment elevation myocardial infarction (NSTEMI) population but are vastly under-represented in trials. Thus, the benefits of an early angiography in the elderly remain unclear. In this systematic review, we compared outcomes of “invasive” and “conservative” strategies of NSTEMI management in elderly patients.

      Methods

      A comprehensive search of major databases was performed. We included comparative studies of any design that enrolled patients ≥ 75 years, and where outcomes of both strategies of NSTEMI management were available.

      Results

      Among the included studies (3 randomized and 6 observational), there were 6340 patients in the “invasive” group and 13,358 patients in the “conservative” group. The 12-month mortality rate (odds ration [OR], 0.45; p < 0.00001), the 30-day mortality (OR, 0.50; p = 0.0009), and events of stroke (OR, 0.42; p < 0.00001) were significantly lower in the invasive group. Major bleeding was higher in the invasive cohort (OR, 1.63; p = 0.03). Analysis of randomised studies showed lower reinfarction with invasive approach at 12 months (p = 0.0001). Significant heterogeneity was noted among studies according to study design.

      Conclusion

      The overall benefit with invasive strategy comes from the data of observational studies that are prone to selection bias. We believe that there is a need for a large randomized study in the elderly patients regarding management of NSTEMI.

      Résumé

      Contexte

      Les patients âgés (≥ 75 ans) forment un important sous-groupe de patients ayant subi un infarctus du myocarde sans sus-décalage du segment ST (NSTEMI), mais sont largement sous représentés dans les essais. Par conséquent, les bienfaits d’une angiographie précoce chez les personnes âgées demeurent nébuleux. Dans cette revue systématique, nous avons comparé les résultats de méthodes de prise en charge « invasives » et « conservatrices » du NSTEMI chez les patients âgés.

      Méthodologie

      Nous avons procédé à une fouille complète des principales bases de données. Nous avons retenu les études comparatives, toutes méthodologies confondues, auxquelles ont participé des patients de 75 ans ou plus et qui indiquaient les issues des deux types de méthodes de prise en charge du NSTEMI.

      Résultats

      Les études retenues (3 à répartition aléatoire et 6 observationnelles) comportaient 6 340 patients dans le groupe de méthodes « invasives » et 13 358 patients dans le groupe de méthodes « conservatrices ». Le taux de mortalité à 12 mois (rapport de cotes [RC], 0,45; p < 0,00001), la mortalité à 30 jours (RC, 0,50; p = 0,0009) et les cas d’AVC (RC, 0,42; p < 0,00001) étaient considérablement plus bas dans le groupe de méthodes invasives que dans l’autre groupe. Les épisodes de saignement important ont été supérieurs dans le groupe de méthodes invasives (RC, 1,63; p = 0,03). Une analyse des études à répartitions aléatoires a révélé un taux de récidives d’infarctus à 12 mois inférieur avec la méthode invasive (p = 0,0001). Une hétérogénéité importante a été observée entre les études quant à leurs méthodologies.

      Conclusion

      Les bienfaits globaux associés à la méthode invasive proviennent de données d’études observationnelles qui sont vulnérbles aux biais de sélection. Nous croyons qu’il existe un besoin pour une vaste étude à répartition aléatoire menée auprès de patients âgés sur la prise en charge du NSTEMI.
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      References

        • Bavry A.A.
        • Kumbhani D.J.
        • Rassi A.N.
        • Bhatt D.L.
        • Askari A.T.
        Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials.
        J Am Coll Cardiol. 2006; 48: 1319-1325
        • Fox K.A.
        • Clayton T.C.
        • Damman P.
        • et al.
        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.
        J Am Coll Cardiol. 2010; 55: 2435-2445
        • Mehta S.R.
        • Cannon C.P.
        • Fox K.A.
        • et al.
        Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials.
        JAMA. 2005; 293: 2908-2917
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        PLoS Med. 2009; 6: e1000100
        • Tooth L.
        • Ware R.
        • Bain C.
        • Purdie D.M.
        • Dobson A.
        Quality of reporting of observational longitudinal research.
        Am J Epidemiol. 2005; 161: 280-288
        • Bach R.G.
        • Cannon C.P.
        • Weintraub W.S.
        • et al.
        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
        • Galasso G.
        • De Servi S.
        • Savonitto S.
        • et al.
        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
        • Tegn N.
        • Abdelnoor M.
        • Aaberge L.
        • et al.
        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
        • Alexander K.P.
        • Newby L.K.
        • Bhapkar M.V.
        • et al.
        • Symphony and 2nd Symphony Investigators
        International variation in invasive care of the elderly with acute coronary syndromes.
        Eur Heart J. 2006; 27: 1558-1564
        • Amann U.
        • Kirchberger I.
        • Heier M.
        • et al.
        Acute myocardial infarction in the elderly: treatment strategies and 28-day-case fatality from the MONICA/KORA myocardial infarction registry.
        Catheter Cardiovasc Interv. 2016; 87: 680-688
        • Bauer T.
        • Koeth O.
        • Junger C.
        • et al.
        • Acute Coronary Syndromes Registry (ACOS) Investigators
        Effect of an invasive strategy on in-hospital outcome in elderly patients with non-ST-elevation myocardial infarction.
        Eur Heart J. 2007; 28: 2873-2878
        • Buber J.
        • Goldenberg I.
        • Kimron L.
        • Guetta V.
        One-year outcome following coronary angiography in elderly patients with non-ST elevation myocardial infarction: Real-world data from the acute coronary syndromes israeli survey (ACSIS).
        Coron Artery Dis. 2013; 24: 102-109
        • Gierlotka M.
        • Gasior M.
        • Tajstra M.
        • et al.
        Outcomes of invasive treatment in very elderly Polish patients with non-ST-segment-elevation myocardial infarction from 2003-2009 (from the PL-ACS registry).
        Cardiol J. 2013; 20: 34-43
        • Lourenco C.
        • Teixeira R.
        • Antonio N.
        • et al.
        Invasive strategy in non-ST elevation acute coronary syndromes: risks and benefits in an elderly population.
        Rev Port Cardiol. 2010; 29: 1451-1472
        • Libungan B.
        • Karlsson T.
        • Albertsson P.
        • Herlitz J.
        Elderly patients with myocardial infarction selected for conservative or invasive treatment strategy.
        Clin Interv Aging. 2015; 10: 321-327
        • Rosengren A.
        • Wallentin L.
        • Simoons M.
        • et al.
        Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey.
        Eur Heart J. 2006; 27: 789-795
        • Fox K.A.
        • Eagle K.A.
        • Gore J.M.
        • Steg P.G.
        • Anderson F.
        The Global Registry of Acute Coronary Events, 1999 to 2009–GRACE.
        Heart. 2010; 96: 1095-1101
        • Roffi M.
        • Patrono C.
        • Collet J.-P.
        • et al.
        2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2016; 37: 267-315
        • Alexander K.
        • Newby K.
        • Cannon C.P.
        • et al.
        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
        • Valgimigli M.
        • Gagnor A.
        • Calabró P.
        • et al.
        Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial.
        Lancet. 2015; 385: 2465-2476
        • Dall'Orto C.C.
        • Lopes R.P.F.
        • Alcântara C.T.
        • et al.
        Percutaneous coronary intervention using transradial access in elderly vs non-elderly patients.
        Rev Bras Cardiol Invasiva. 2013; 21: 36-42
        • Lichtman J.H.
        • Krumholz H.M.
        • Wang Y.
        • Radford M.J.
        • Brass L.M.
        Risk and predictors of stroke after myocardial infarction among the elderly.
        Circulation. 2002; 105: 1082-1087

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