An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction (NSTEMI) or unstable angina, according to the After Eighty trial.

Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group due to comorbidities,” Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. “These factors may reduce the benefits and increase the risk of complications from invasive treatment.”

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41 percent vs. 61 percent, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48 percent less likely to experience MI and 81 percent less likely to require urgent revascularization. They were also 40 percent less likely to have a stroke and 11 percent less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10 percent) than in the conservative strategy group (7 percent).

“The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina,” Dr. Bendz and Dr. Tegn said. “However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference.”

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, “The After-80 study now provides the direct evidence we needed to support this ‘early invasive’ approach. Given how difficult it is to recruit very elderly patients to clinical studies – and this was reflected by the fact that almost 80 percent of screened patients were not actually enrolled into After-80 – the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many ‘very old’ patients admitted to our cardiology and general medicine wards with ACS.”

“In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70 percent to 80 percent of patients who were screened for this study were ultimately not enrolled,” he reiterated. “There would have been many reasons why so many patients were excluded, but it does emphasize that the study’s findings won’t apply to everyone over the age of 80 who presents with ACS.”

“As always, the decision making process needs to be individually tailored,” Dr. Psaltis said. “The patient’s pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account.”

“Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts,” Dr. Psaltis added. “In certain individuals [older than] 90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even the use of anti-anginal medications that can be associated with debilitating side-effects.”

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, “Conservative treatment does not result in a poor outcome in every patient and we need to know much more about differential approach.”

“However, active treatment remains a great option for part of the elderly patients,” regardless of age, he told Reuters Health by email. “Please note the increasing number of patients treated at age above 100 years which proves to be a good option if the patients want to live actively.”

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of angioplasty in octogenarian ACS patients.

He told Reuters Health by email, “This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period.”

The study did not have commercial funding and the researchers declared no competing interests.