Invasive strategy provides better outcomes for very elderly patients with NSTEACS

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Alberto Arizo-Sole

A study in EuroIntervention indicates that very elderly patients—mean age 84.3 years—with non-ST-segment elevation acute coronary syndromes (NSTEACS) who undergo invasive therapy have a lower rate of cardiac events compared with those who undergo a conservative approach. Additionally, the association between the rate of cardiac events and type of therapy was different according to the frailty status of the patient. Cardiovascular News spoke to study author Albert Ariza-Solé (Hospital Universitario de Bellvitge, Barcelona, Spain) about the findings.

Prior to your study, what evidence was available for the management of NSTEACS in frail elderly patients?

Evidence regarding this topic is scarce, since frail elderly patients are often excluded from clinical trials. There are three recent clinical trials addressing the role of an invasive strategy in elderly patients with NSTEACS and they show conflicting results. However, information about frailty and other components of a geriatric evaluation were not available in these studies, so it is difficult to know how those patients were selected.

Therefore, we believe that our study provides novel and interesting data about the potential impact of an invasive strategy in very elderly patients with NSTEACS according to their frailty status.

Do you think perceived old age/frailty dissuades people from performing invasive interventions in elderly patients?

Yes, absolutely! Registries consistently show a strong association between the degree of frailty and a lower likelihood of undergoing an invasive strategy during admission.

In your study, how did you assess frailty?

We used a very quick and easy to tool to assess frailty in the acute setting—the FRAIL scale. It is a five-item interview based evaluation that can be easily performed in less than one minute.

What were the key findings of your study?

In our opinion, the most important finding from our study is that an invasive strategy during the admission was associated with a lower incidence of reinfarction, need for coronary revascularisation or cardiac mortality at six months in this cohort of unselected very elderly patients with NSEACS from routine clinical practice. Additionally, the benefit of an invasive strategy was different according frailty status—suggesting a lower impact on outcomes in elderly patients with stablished frailty criteria.

How did they differ?

While an invasive strategy during the admission was associated with a significantly lower incidence of the primary outcome in the whole cohort, this association was not significant in patients with established frailty.

Based on the available evidence, which elderly NSTEACS patients would benefit the most from an invasive strategy?

We believe that, taking into account these data, most robust or “prefrail” elderly patients with NSTEACS should undergo an invasive strategy. In contrast, patients with established frailty criteria and disability should undergo an individualised approach.

What further evidence is needed in this area?

Given the observational nature of this study, we cannot exclude some degree of selection bias and residual confounding factors. In fact, patients conservatively managed from our series had the highest degree of frailty and comorbidities. Therefore, the next step in investigating this area is a randomised trial comparing an invasive vs. conservative strategy in this poorly studied subset of patients.

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