Invasive strategy reduced 6-month mortality in ACS patients aged ≥80 (STEMI: 26.8% vs 49.4%, NSTE-ACS: 10.9% vs 32.1%), HR 0.58, p=0.036.
Does an invasive strategy reduce all-cause mortality in patients aged 80 or older with acute coronary syndrome compared to a conservative strategy?
In patients aged 80 or older with acute coronary syndrome, an invasive strategy is associated with significantly lower 6-month all-cause mortality compared to conservative management, without a significant increase in major bleeding.
Abstract Background Older patients with acute coronary syndrome (ACS), including both ST-elevation myocardial infarction (STEMI) and non-ST-elevation ACS (NSTE-ACS), are less frequently treated with an invasive approach, which may negatively impact their survival. Many studies often exclude older populations due to age, multimorbidity, and geriatric syndrome, resulting in a lack of data on the effectiveness of revascularization strategies in this patient group. Purpose To investigate the choice of therapeutic approach in elderly ACS patients and compare the outcomes between the invasively and conservatively treated groups. Methods This retrospective study included consecutive patients aged 80 or older who presented with ACS at two tertiary institutions from November 2018 to October 2023. The invasive group consisted of patients who underwent percutaneous coronary intervention or coronary artery bypass graft surgery. The conservative strategy was defined as guideline-directed medical therapy, with or without coronary angiography. The primary outcome was all-cause mortality during the 6-month follow-up. Secondary outcomes were recurrent myocardial infarction (MI) and cerebrovascular incident (CVI). Results Among 670 patients with a median age of 83 years 81–86 and 50.6% women, 307 (45.8%) had STEMI, and 363 (54.2%) had NSTE-ACS. A total of 429 (64%) ACS patients were treated with an invasive strategy, significantly more often in the STEMI group (74.3% vs. 55.4%, p 0.001). There was no significant difference in major bleeding between ACS patients treated with an invasive approach and those managed conservatively (2.8% vs. 1.7%, p = 0.355). During the 6-month follow-up, a total of 174 (26%) patients died, with significantly higher mortality in the STEMI group (32.6% vs. 20.4%, p 0.001). Patients treated with an invasive strategy had significantly lower in-hospital mortality (STEMI: 10.1% vs. 31.6%, p 0.001; NSTE-ACS: 2.5% vs. 8.6%, p = 0.009) and 6-month mortality (STEMI: 26.8% vs. 49.4%, p 0.001; NSTE-ACS: 10.9% vs. 32.1%, p 0.001) compared to those treated conservatively. Recurrent MI occurred in 2.5% of all ACS patients, while CVI was recorded in 1.2% during follow-up, with no differences in incidence based on ACS type or treatment approach. Multivariable regression analysis identified invasive strategy (HR = 0.58; 95% CI: 0.35–0.96; p = 0.036) and renin-angiotensin-aldosterone system inhibitor therapy at discharge (HR = 0.38; 95% CI: 0.24–0.61; p 0.001) as positive predictors of 6-month survival in all ACS patients. Conclusions Our study showed that older NSTE-ACS patients were less frequently treated with an invasive approach than STEMI patients. The invasive treatment strategy was associated with lower mortality in this population, regardless of the type of ACS. The incidence of recurrent MI and CVI did not differ between groups treated with different therapeutic approaches.
Gjuras et al. (2025) studied this question. Invasive strategy reduced 6-month mortality in ACS patients aged ≥80 (STEMI: 26.8% vs 49.4%, NSTE-ACS: 10.9% vs 32.1%), HR 0.58, p=0.036.