title: Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial.
abstract: OBJECTIVE
  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).
  
  
  BACKGROUND
  Elderly patients have been scarcely represented in trials comparing treatment strategies in NSTEACS.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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).
authors.affiliation: Azienda Ospedaliera Santa Maria Nuova, IRCCS, Reggio Emilia, Italy. stefano.savonitto@asmn.re.it
authors.forename: Stefano
authors.initials: S
authors.lastname: Savonitto
authors.forename: Claudio
authors.initials: C
authors.lastname: Cavallini
authors.forename: A Sonia
authors.initials: AS
authors.lastname: Petronio
authors.forename: Ernesto
authors.initials: E
authors.lastname: Murena
authors.forename: Roberto
authors.initials: R
authors.lastname: Antonicelli
authors.forename: Alice
authors.initials: A
authors.lastname: Sacco
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Steffenino
authors.forename: Francesco
authors.initials: F
authors.lastname: Bonechi
authors.forename: Ernesto
authors.initials: E
authors.lastname: Mossuti
authors.forename: Antonio
authors.initials: A
authors.lastname: Manari
authors.forename: Salvatore
authors.initials: S
authors.lastname: Tolaro
authors.forename: Anna
authors.initials: A
authors.lastname: Toso
authors.forename: Alessandro
authors.initials: A
authors.lastname: Daniotti
authors.forename: Federico
authors.initials: F
authors.lastname: Piscione
authors.forename: Nuccia
authors.initials: N
authors.lastname: Morici
authors.forename: Bruno M
authors.initials: BM
authors.lastname: Cesana
authors.forename: M Cristina
authors.initials: MC
authors.lastname: Jori
authors.forename: Stefano
authors.initials: S
authors.lastname: De Servi
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D002317:Cardiovascular Agents / Q000627:therapeutic use; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D009203:Myocardial Infarction / Q000209:etiology; D010359:Patient Readmission; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality; D019106:Postoperative Hemorrhage / Q000209:etiology; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome; D014336:Troponin / Q000097:blood; D015854:Up-Regulation
chemical_list: D015415:Biomarkers; D002317:Cardiovascular Agents; D014336:Troponin