title: Randomized comparison between the invasive and conservative strategies in comorbid elderly patients with non-ST elevation myocardial infarction.
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 70years 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).
authors.affiliation: Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain. Electronic address: sanchis_juafor@gva.es.
authors.forename: Juan
authors.initials: J
authors.lastname: Sanchis
authors.affiliation: Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Núñez
authors.affiliation: Department of Cardiology, Hospital Universitari Vall d'Hebrón, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: José Antonio
authors.initials: JA
authors.lastname: Barrabés
authors.affiliation: Department of Cardiology, Hospital Virgen Arrixaca, Murcia, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: Marín
authors.affiliation: Department of Cardiology, Hospital Santa Lucía, Cartagena, Spain.
authors.forename: Luciano
authors.initials: L
authors.lastname: Consuegra-Sánchez
authors.affiliation: Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain.
authors.forename: Silvia
authors.initials: S
authors.lastname: Ventura
authors.affiliation: Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain.
authors.forename: Ernesto
authors.initials: E
authors.lastname: Valero
authors.affiliation: Department of Cardiology, Hospital Clinic, Barcelona, Spain.
authors.forename: Mercè
authors.initials: M
authors.lastname: Roqué
authors.affiliation: Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
authors.forename: Antoni
authors.initials: A
authors.lastname: Bayés-Genís
authors.affiliation: Department of Cardiology, Hospital Universitari Vall d'Hebrón, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Bruno García
authors.initials: BG
authors.lastname: Del Blanco
authors.affiliation: IMIM (Hospital del Mar Medical Research Institute), Universitat Autonoma de Barcelona, Barcelona, Spain.
authors.forename: Irene
authors.initials: I
authors.lastname: Dégano
authors.affiliation: Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain.
authors.forename: Julio
authors.initials: J
authors.lastname: Núñez
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D006328:Cardiac Catheterization; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D015897:Comorbidity; D017023:Coronary Angiography; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D000072658:Non-ST Elevated Myocardial Infarction / Q000401:mortality* / Q000628:therapy*; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012042:Registries; D013030:Spain; D016896:Treatment Outcome
chemical_list: D002317:Cardiovascular Agents
keywords: Comorbidities; Elderly; Invasive management; Non-ST elevation myocardial infarction