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Elderly NSTEMI patients benefit from invasive treatment

The Lancet
Reuters Health - 03/09/2020 - Invasive treatment gives patients 80 years and older with non-ST elevation myocardial infarction (NSTEMI) a five-year survival advantage along with fewer admissions for heart failure, a UK study suggests.

Researchers examined data on patients 80 and older who underwent troponin measurements and were diagnosed with NSTEMI from 2010 to 2017. Out of 1,976 patients, 101 died within three days of their peak troponin concentration and 375 were excluded due to extreme propensity scores, leaving a study population of 1,500.

Patients in the study had a median age of 86 years, and 845 (56%) received non-invasive management for NSTEMI. During a median follow-up of three years, 613 patients (41%) died.

Researchers calculated that adjusted cumulative 5-year mortality was 36% with invasive management and 55% with non-invasive management (adjusted hazard ratio 0.68).

"Although invasive treatment is generally safe, risk of complications, including death, are higher in older patients, which may deter doctors from performing such procedures on them," said lead study author Dr. Amit Kaura of Imperial College London.

"While the decisions about the best way to treat any elderly patient will depend on their individual circumstance - this study shows that age alone should not be a barrier to patients receiving lifesaving procedures for heart attacks," Dr. Kaura said by email.

In addition to the survival advantage, invasive management was also associated with a lower incidence of hospital admissions for heart failure (adjusted rate ratio 0.67) than non-invasive management.

The analysis also showed that patients were at no greater risk of complications like stroke or bleeding if they received invasive treatment, Dr. Kaura said.

Due to the observational nature of the study, uncontrolled confounding bias is possible, the study team notes in The Lancet. Patients with worse prognosis were more likely to receive non-invasive management.

The survival benefit seen in the study is surprising, said Dr. Bjorn Bendz head of the division of cardiovascular and pulmonary diseases at Oslo University Hospital in Norway and co-author of an editorial accompanying the study.

While clinical decision making should ideally be driven by randomized controlled trials, NSTEMI research that meets this standard has generally excluded patients over 80 years old, Dr. Bendz writes.

Clinicians should make treatment decisions in older patients on an individual basis, considering factors such as life expectancy, comorbidities, ischemic versus bleeding risk, frailty, and individual patient preferences, Dr. Bendz adds.

"The results from the present study could help to better assess the relation between benefit and risk when treating this challenging group of patients," Dr. Bendz told Reuters Health by email.

By Lisa Rapaport

SOURCE: https://bit.ly/2Z5xm5X and https://bit.ly/31SsmUa The Lancet, online August 29, 2020. (Editing by Christine Soares)

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