Invasive Treatment Strategy for Older Patients with Myocardial Infarction

British Heart Foundation SENIOR-RITA Trial Team and Investigators; Vijay Kunadian; Helen Mossop; Carol Shields; Michelle Bardgett; Philippa Watts; M. Dawn Teare; Jonathan Pritchard; Jennifer Adams-Hall; Craig Runnett; David P. Ripley; Justin Carter; Julie Quigley; Justin Cooke; David Austin; Jerry Murphy; Damian Kelly; James McGowan; Murugapathy Veerasamy; Dirk Felmeden; Hussain Contractor; Sanjay Mutgi; John Irving; Steven Lindsay; Gavin Galasko; Kelvin Lee; Ayyaz Sultan; Amardeep G. Dastidar; Shazia Hussain; Iftikhar ul Haq; Mark de Belder; Martin Denvir; Marcus Flather; Robert F. Storey; David E Newby; Stuart J. Pocock; Keith A.A. Fox

doi:10.1056/NEJMoa2407791

Invasive Treatment Strategy for Older Patients with Myocardial Infarction

British Heart Foundation SENIOR-RITA Trial Team and Investigators, Vijay Kunadian^*, Helen Mossop, Carol Shields, Michelle Bardgett, Philippa Watts, M. Dawn Teare, Jonathan Pritchard, Jennifer Adams-Hall, Craig Runnett, David P. Ripley, Justin Carter, Julie Quigley, Justin Cooke, David Austin, Jerry Murphy, Damian Kelly, James McGowan, Murugapathy Veerasamy, Dirk FelmedenHussain Contractor, Sanjay Mutgi, John Irving, Steven Lindsay, Gavin Galasko, Kelvin Lee, Ayyaz Sultan, Amardeep G. Dastidar, Shazia Hussain, Iftikhar ul Haq, Mark de Belder, Martin Denvir, Marcus Flather, Robert F. Storey, David E Newby, Stuart J. Pocock, Keith A.A. Fox

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

Abstract / Description of output

Background
Whether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non–ST-segment elevation myocardial infarction (NSTEMI) remains unclear.
Methods
We conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis.
Results
A total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P=0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients.
Conclusions
In older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.)

Original language	English
Journal	New England Journal of Medicine
DOIs	https://doi.org/10.1056/NEJMoa2407791
Publication status	Published - 1 Sept 2024

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Kunadian-2407791-TextAccepted author manuscript, 113 KBLicence: Creative Commons: Attribution (CC-BY)

http://www.nejm.org/doi/10.1056/NEJMoa2407791

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British Heart Foundation SENIOR-RITA Trial Team and Investigators, Kunadian, V., Mossop, H., Shields, C., Bardgett, M., Watts, P., Teare, M. D., Pritchard, J., Adams-Hall, J., Runnett, C., Ripley, D. P., Carter, J., Quigley, J., Cooke, J., Austin, D., Murphy, J., Kelly, D., McGowan, J., Veerasamy, M., ... Fox, K. A. A. (2024). Invasive Treatment Strategy for Older Patients with Myocardial Infarction. New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2407791

@article{8afb2b41e35841f1812c1f53ea612c9c,

title = "Invasive Treatment Strategy for Older Patients with Myocardial Infarction",

abstract = "BackgroundWhether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non–ST-segment elevation myocardial infarction (NSTEMI) remains unclear.MethodsWe conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis.ResultsA total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P=0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients.ConclusionsIn older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.)",

author = "{British Heart Foundation SENIOR-RITA Trial Team and Investigators} and Vijay Kunadian and Helen Mossop and Carol Shields and Michelle Bardgett and Philippa Watts and Teare, {M. Dawn} and Jonathan Pritchard and Jennifer Adams-Hall and Craig Runnett and Ripley, {David P.} and Justin Carter and Julie Quigley and Justin Cooke and David Austin and Jerry Murphy and Damian Kelly and James McGowan and Murugapathy Veerasamy and Dirk Felmeden and Hussain Contractor and Sanjay Mutgi and John Irving and Steven Lindsay and Gavin Galasko and Kelvin Lee and Ayyaz Sultan and Dastidar, {Amardeep G.} and Shazia Hussain and Haq, {Iftikhar ul} and {de Belder}, Mark and Martin Denvir and Marcus Flather and Storey, {Robert F.} and Newby, {David E} and Pocock, {Stuart J.} and Fox, {Keith A.A.}",

year = "2024",

month = sep,

day = "1",

doi = "10.1056/NEJMoa2407791",

language = "English",

journal = "New England Journal of Medicine",

issn = "0028-4793",

publisher = "MASSACHUSETTS MEDICAL SOC",

}

British Heart Foundation SENIOR-RITA Trial Team and Investigators, Kunadian, V, Mossop, H, Shields, C, Bardgett, M, Watts, P, Teare, MD, Pritchard, J, Adams-Hall, J, Runnett, C, Ripley, DP, Carter, J, Quigley, J, Cooke, J, Austin, D, Murphy, J, Kelly, D, McGowan, J, Veerasamy, M, Felmeden, D, Contractor, H, Mutgi, S, Irving, J, Lindsay, S, Galasko, G, Lee, K, Sultan, A, Dastidar, AG, Hussain, S, Haq, IU, de Belder, M, Denvir, M, Flather, M, Storey, RF, Newby, DE, Pocock, SJ & Fox, KAA 2024, 'Invasive Treatment Strategy for Older Patients with Myocardial Infarction', New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2407791

TY - JOUR

T1 - Invasive Treatment Strategy for Older Patients with Myocardial Infarction

AU - British Heart Foundation SENIOR-RITA Trial Team and Investigators

AU - Kunadian, Vijay

AU - Mossop, Helen

AU - Shields, Carol

AU - Bardgett, Michelle

AU - Watts, Philippa

AU - Teare, M. Dawn

AU - Pritchard, Jonathan

AU - Adams-Hall, Jennifer

AU - Runnett, Craig

AU - Ripley, David P.

AU - Carter, Justin

AU - Quigley, Julie

AU - Cooke, Justin

AU - Austin, David

AU - Murphy, Jerry

AU - Kelly, Damian

AU - McGowan, James

AU - Veerasamy, Murugapathy

AU - Felmeden, Dirk

AU - Contractor, Hussain

AU - Mutgi, Sanjay

AU - Irving, John

AU - Lindsay, Steven

AU - Galasko, Gavin

AU - Lee, Kelvin

AU - Sultan, Ayyaz

AU - Dastidar, Amardeep G.

AU - Hussain, Shazia

AU - Haq, Iftikhar ul

AU - de Belder, Mark

AU - Denvir, Martin

AU - Flather, Marcus

AU - Storey, Robert F.

AU - Newby, David E

AU - Pocock, Stuart J.

AU - Fox, Keith A.A.

PY - 2024/9/1

Y1 - 2024/9/1

N2 - BackgroundWhether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non–ST-segment elevation myocardial infarction (NSTEMI) remains unclear.MethodsWe conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis.ResultsA total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P=0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients.ConclusionsIn older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.)

AB - BackgroundWhether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non–ST-segment elevation myocardial infarction (NSTEMI) remains unclear.MethodsWe conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis.ResultsA total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P=0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients.ConclusionsIn older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.)

U2 - 10.1056/NEJMoa2407791

DO - 10.1056/NEJMoa2407791

M3 - Article

SN - 0028-4793

JO - New England Journal of Medicine

JF - New England Journal of Medicine

ER -

Invasive Treatment Strategy for Older Patients with Myocardial Infarction

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