An Invasive vs a Conservative Approach in Elderly Patients with Non–ST-Segment Elevation Myocardial Infarction: Systematic Review and Meta-Analysis

• Published in: Canadian journal of cardiology 2018-03, Vol.34 (3), p.274-280
• Main Authors: Saraswat, Avadhesh, Rahman, Atifur, Singh, Kuljit
• Format: Article
• Language: English
• Subjects: Age Factors; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors - therapeutic use; Conservative Treatment; Coronary Angiography - methods; Coronary Artery Bypass - methods; Electrocardiography - methods; Female; Geriatric Assessment; Humans; Male; Myocardial Infarction - diagnostic imaging; Myocardial Infarction - mortality; Myocardial Infarction - therapy; Patient Selection; Percutaneous Coronary Intervention - methods; Percutaneous Coronary Intervention - mortality; Platelet Aggregation Inhibitors - therapeutic use; Prognosis; Risk Assessment; Severity of Illness Index; Survival Analysis; Treatment Outcome
• ISSN: 0828-282X; 1916-7075
• DOI: 10.1016/j.cjca.2017.11.020

Elderly (≥ 75 years) patients form a large sub-group of non–ST-segment elevation myocardial infarction (NSTEMI) population but are vastly under-represented in trials. Thus, the benefits of an early angiography in the elderly remain unclear. In this systematic review, we compared outcomes of “invasive” and “conservative” strategies of NSTEMI management in elderly patients. A comprehensive search of major databases was performed. We included comparative studies of any design that enrolled patients ≥ 75 years, and where outcomes of both strategies of NSTEMI management were available. Among the included studies (3 randomized and 6 observational), there were 6340 patients in the “invasive” group and 13,358 patients in the “conservative” group. The 12-month mortality rate (odds ration [OR], 0.45; p < 0.00001), the 30-day mortality (OR, 0.50; p = 0.0009), and events of stroke (OR, 0.42; p < 0.00001) were significantly lower in the invasive group. Major bleeding was higher in the invasive cohort (OR, 1.63; p = 0.03). Analysis of randomised studies showed lower reinfarction with invasive approach at 12 months (p = 0.0001). Significant heterogeneity was noted among studies according to study design. The overall benefit with invasive strategy comes from the data of observational studies that are prone to selection bias. We believe that there is a need for a large randomized study in the elderly patients regarding management of NSTEMI. Les patients âgés (≥ 75 ans) forment un important sous-groupe de patients ayant subi un infarctus du myocarde sans sus-décalage du segment ST (NSTEMI), mais sont largement sous représentés dans les essais. Par conséquent, les bienfaits d’une angiographie précoce chez les personnes âgées demeurent nébuleux. Dans cette revue systématique, nous avons comparé les résultats de méthodes de prise en charge « invasives » et « conservatrices » du NSTEMI chez les patients âgés. Nous avons procédé à une fouille complète des principales bases de données. Nous avons retenu les études comparatives, toutes méthodologies confondues, auxquelles ont participé des patients de 75 ans ou plus et qui indiquaient les issues des deux types de méthodes de prise en charge du NSTEMI. Les études retenues (3 à répartition aléatoire et 6 observationnelles) comportaient 6 340 patients dans le groupe de méthodes « invasives » et 13 358 patients dans le groupe de méthodes « conservatrices ». Le taux de mortalité à 12 mois (rapport de cotes [RC], 0,45; p < 0,00001), la