Early Invasive Strategy Dramatically Lowers Risk of Death, MI in Older NSTE-ACS Patients

SAN DIEGO, CA—Patients over age 80 who have NSTE-ACS or unstable angina are less likely to die, suffer an MI, or need urgent revascularization with an early invasive strategy compared with conservative management, according to a study presented March 16, 2015, at the American College of Cardiology/i2 Scientific Session.

For the After Eighty study, Nicolai Kloumann Tegn, MD, of Oslo University Hospital (Oslo, Norway), and colleagues looked at 457 stable patients over age 80 treated at 17 health centers in Norway between December 2010 and February 2014. Patients who were asymptomatic for chest pain or other ischemic symptoms/signs were randomized to an invasive (n = 229) or conservative strategy (n = 228). According to Dr. Tegn, the minimum life expectancy required for randomization was 12 months based on individual physician judgment.

The overall mean age was about 84 years and about half of all patients were women. More than half of patients in both arms had previous angina and hypertension, and the vast majority had elevated troponin levels.

Among patients in the invasive group, 47% underwent PCI—most (86%) with radial access—and 3% underwent CABG. Angiographic findings showed 3-vessel or left main disease in 30%, 2-vessel disease in 21%, 1-vessel disease in 21%, and no stenosis in 22%.

Clear Advantage for Revascularization

Compared with a conservative approach, those who underwent an invasive strategy had a decrease in the primary composite endpoint (MI, need for urgent revascularization, stroke, and death) at a median follow up of 18 months. An invasive strategy was also associated with lower rates of MI, urgent revascularization, and the composite of death/MI compared with a conservative approach. There were no differences between the groups for the secondary endpoints of stroke or death from any cause.

Additionally, no differences in bleeding were observed between the 2 groups.

Shedding Light on an Ignored Population

In an interview with TCTMD, Dr. Tegn said octogenarians are a heterogenous group and that despite an average life expectancy of about 9 years, it can be difficult to predict the length and quality of the rest of their lives. As a result, he said, studies such as After Eighty shed light on a population that is often excluded from randomized trials and denied invasive treatment based on age alone.

In a press conference following Dr. Tegn’s presentation, discussant David E. Kandzari, MD, of the Piedmont Heart Institute (Atlanta, GA), said the study is a welcome addition considering the challenges presented by the over 80 population.

He concluded that the study “reminds us that the coronary anatomy is not [necessarily representative] of the age of the patient,” and suggested that additional studies include endpoints related to quality of life, which are ”equally important considerations for individuals of advanced age.”