September 2024: Invasive Treatment Strategy for Older Patients with Myocardial Infarction
The issue
For adults ≥ 75 admitted with non‑ST‑segment‑elevation heart attack (NSTEMI), routinely taking everyone to the cath‑lab for angiography and possible stent placement did not improve survival compared with optimized drug therapy alone in the 1,518‑patient SENIOR‑RITA trial.
What do I need to know?
Participants (mean age 82; 45 % women; one‑third frail) were randomized to an invasive strategy (angiography plus revascularization when indicated) or a conservative strategy (best medical therapy). After a median 4.1 years, the primary composite of cardiovascular death or non‑fatal myocardial infarction was virtually identical: 25.6 % with the invasive plan versus 26.3 % with conservative care (hazard ratio 0.94). Non‑fatal MIs alone were fewer with the invasive approach (11.7 % vs 15.0 %; HR 0.75). Roughly half the invasive‑arm patients actually received a stent or bypass, procedures were done a median five days after admission, and serious complications were < 1 %.
Potential risk of overtreatment
Older adult with stable coronary disease risk factors but no acute chest‑pain episode.
Recommended Actions
Keep blood pressure, cholesterol, and diabetes well controlled.
Discuss advance directives and care goals before any emergency.
Ask whether non‑invasive stress testing is sufficient for routine follow‑up.
Imminent risk of overtreatment
Hospitalized with suspected NSTEMI but hemodynamically stable while clinicians weigh invasive versus medical care.
Recommended Actions
Request a geriatric/cardiology consult to assess frailty, bleeding, cognition, and life expectancy.
Compare potential benefit (fewer repeat heart attacks) with risks (bleeding, kidney injury, procedural delay).
Ensure drug therapy (dual antiplatelet, statin, beta‑blocker) starts promptly regardless of chosen strategy.
Confirmed NSTEMI requiring a plan
NSTEMI plus ongoing chest pain, heart‑failure signs, or major ECG changes.
Recommended Actions
Proceed with angiography if team believes revascularization will improve quality of life; insist on bleeding‑avoidance tactics (radial access, proton‑pump inhibitor).
If frailty or comorbidities outweigh benefit, pursue optimal medical therapy and cardiac rehab.
Arrange close follow‑up within two weeks of discharge to adjust medicines and monitor symptoms.
What can I do?
Ask the care team, “Am I (or my loved one) at potential, imminent, or confirmed risk that justifies an invasive approach?” Bring a current medication list, any bleeding history, and mobility aids to help assess procedural risk. Remember that choosing conservative management is reasonable for many seniors; drugs plus lifestyle change still protect the heart. If angiography is selected, request it early—waiting several days may blunt any advantage—and confirm the plan to manage nausea, kidney function, and post‑procedure rehabilitation.
