January 2025: Invasive Strategy for Older Patients with MI
The issue
A major trial in adults ≥ 75 with non‑ST‑segment–elevation heart attacks (NSTEMI) found that routinely sending everyone for angiography and possible stent surgery did not lower the death rate compared with careful medical therapy alone.
What do I need to know?
In the SENIOR‑RITA study, only half of the patients assigned to the “invasive” arm actually received a stent, partly because the average wait for the procedure was five days. Still, the invasive strategy did cut non‑fatal heart‑attack recurrences but offered no survival edge. Decisions were highly individualized: doctors weighed bleeding risk, frailty, cognition, life expectancy, and patient preferences before choosing invasive or conservative care. Current guidelines now rate early (within 24 h) angiography in older NSTEMI patients as optional rather than essential because pooled data show no clear mortality benefit.
Potential risk of overtreatment
Older adult with stable coronary‑artery disease risk factors but no current heart‑attack symptoms.
Recommended Actions
Keep blood pressure, cholesterol, and diabetes well controlled.
Discuss advance directives and personal goals of care before any emergency arises.
Ask the cardiologist whether non‑invasive stress testing is enough for routine follow‑up.
Imminent risk of overtreatment
Patient is hospitalized with suspected NSTEMI but remains stable; doctors are deciding between immediate angiography or medical therapy.
Recommended Actions
Request a geriatric or cardiology consult to assess frailty, bleeding risk, and cognitive status.
Ask the team to explain potential benefits (fewer repeat MIs) versus risks (bleeding, kidney injury) of an invasive approach.
Ensure the care plan includes early initiation of antiplatelet drugs, statins, and beta‑blockers regardless of strategy.
Confirmed NSTEMI requiring a plan
NSTEMI diagnosis plus high‑risk features (recurrent pain, heart‑failure signs, or major ECG changes).
Recommended Actions
Proceed with angiography if the team believes revascularization will improve quality of life and recovery; insist on bleeding‑avoidance strategies (radial access, proton‑pump inhibitors).
If frailty or comorbidities outweigh benefits, pursue optimal medical therapy and cardiac‑rehab enrollment.
Schedule close outpatient follow‑up within two weeks of discharge to adjust medicines and monitor symptoms.
What can I do?
Tell the cardiology team, “Am I (or my loved one) at potential, imminent, or confirmed risk that warrants an invasive approach?” Bring a list of medications, bleeding history, and mobility aids to help evaluate procedure risk. Know that saying no to angiography is reasonable for some seniors; medical therapy plus lifestyle changes can still provide strong protection. If angiography is chosen, ask that it be performed promptly—delays of several days, as seen in the trial, may blunt any benefit.
