title: 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.
abstract: OBJECTIVE
  To perform a patient-pooled analysis of a routine invasive versus a selective invasive strategy in elderly patients with non-ST segment elevation acute coronary syndrome.
  
  
  METHODS
  A meta-analysis was performed of patient-pooled data from the FRISC II-ICTUS-RITA-3 (FIR) studies. (Un)adjusted HRs were calculated by Cox regression, with adjustments for variables associated with age and outcomes. The main outcome was 5-year cardiovascular death or myocardial infarction (MI) following routine invasive versus selective invasive management.
  
  
  RESULTS
  Regarding the 5-year composite of cardiovascular death or MI, the routine invasive strategy was associated with a lower hazard in patients aged 65-74 years (HR 0.72, 95% CI 0.58 to 0.90) and those aged ≥75 years (HR 0.71, 95% CI 0.55 to 0.91), but not in those aged <65 years (HR 1.11, 95% CI 0.90 to 1.38), p=0.001 for interaction between treatment strategy and age. The interaction was driven by an excess of early MIs in patients <65 years of age; there was no heterogeneity between age groups concerning cardiovascular death. The benefits were smaller for women than for men (p=0.009 for interaction). After adjustment for other clinical risk factors the HRs remained similar.
  
  
  CONCLUSIONS
  The current analysis of the FIR dataset shows that the long-term benefit of the routine invasive strategy over the selective invasive strategy is attenuated in younger patients aged <65 years and in women by the increased risk of early events which seem to have no consequences for long-term cardiovascular mortality. No other clinical risk factors were able to identify patients with differential responses to a routine invasive strategy. Trial registration http://www.controlled-trials.com/ISRCTN82153174 (ICTUS), http://www.controlled-trials.com/ISRCTN07752711 (RITA-3).
authors.affiliation: Department of Cardiology, Academic Medical Center-University of Amsterdam, The Netherlands.
authors.forename: Peter
authors.initials: P
authors.lastname: Damman
authors.forename: Tim
authors.initials: T
authors.lastname: Clayton
authors.forename: Lars
authors.initials: L
authors.lastname: Wallentin
authors.forename: Bo
authors.initials: B
authors.lastname: Lagerqvist
authors.forename: Keith A A
authors.initials: KA
authors.lastname: Fox
authors.forename: Alexander
authors.initials: A
authors.lastname: Hirsch
authors.forename: Fons
authors.initials: F
authors.lastname: Windhausen
authors.forename: Eva
authors.initials: E
authors.lastname: Swahn
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Pocock
authors.forename: Jan G P
authors.initials: JG
authors.lastname: Tijssen
authors.forename: Robbert J
authors.initials: RJ
authors.lastname: de Winter
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000367:Age Factors; D002423:Cause of Death / Q000639:trends; D004562:Electrocardiography; D005500:Follow-Up Studies; D006801:Humans; D009017:Morbidity / Q000639:trends; D009204:Myocardial Revascularization / Q000379:methods*; D009426:Netherlands / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment / Q000379:methods*; D012720:Severity of Illness Index; D015996:Survival Rate / Q000639:trends; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome