Long-Term Follow-Up Confirms Efficacy of Invasive Strategy in Very Old Patients with Non-ST-Elevation ACS
In this long-term analysis of patients in the After Eighty Study, with a mean age of 85 years and non-ST-elevation acute coronary syndrome, an invasive strategy showed a reduction in a composite endpoint of major adverse cardiovascular events and was associated with a significant improvement in event-free survival compared with a conservative approach.
This is a summarized version of the full in-depth article on Relias Media.
By Jeffrey Zimmet, MD, PhD. Associate Professor of Medicine, University of California, San Francisco; Director, Cardiac Catheterization Laboratory, San Francisco VA Medical Center.
Introduction
Non-ST-elevation acute coronary syndromes (NSTE-ACS) are a common clinical presentation, and current guidelines recommend an invasive management strategy for eligible patients. However, the evidence supporting this approach is based mostly on studies with a mean patient age in the early 60s. Conducting trials focused on elderly populations has been challenging, with many studies underpowered to draw firm conclusions. The After Eighty trial aimed to address this gap by examining the benefits of invasive vs. conservative treatment strategies in patients aged 80 years and older presenting with NSTE-ACS.
Trial Design and Patient Population
The After Eighty trial was a multicenter, randomized controlled study conducted in Norway. It enrolled 457 patients aged 80 years or older who presented with NSTE-ACS at 16 non-percutaneous coronary intervention (PCI)-capable hospitals. Patients eligible for the study were clinically stable, excluding those with cardiogenic shock, active bleeding, or ongoing chest pain. They also needed an estimated life expectancy of at least 12 months, and those with significant dementia or comorbidities affecting medication adherence were excluded. Patients randomized to the invasive strategy were transferred to Oslo University Hospital for coronary angiography, while those in the conservative strategy were treated medically at their admitting hospital.
Of the more than 4,000 patients aged 80 years or older admitted with NSTE-ACS during the four-year inclusion period, 47% met the inclusion criteria, but only 23% were ultimately enrolled in the trial. The mean age of participants was 85 years, and nearly half were women.
Results
The trial’s primary outcome was a composite of death, myocardial infarction (MI), urgent revascularization, and stroke. At a median follow-up of 5.3 years, the invasive management group showed a significantly lower incidence of the primary outcome compared to the conservative management group. The incidence rate ratio (IRR) for the composite outcome was 0.76 (95% confidence interval [CI], 0.63-0.93; P = 0.0057).
When analyzing the components of the primary outcome individually:
- The rate of MI was significantly lower in the invasive group (IRR, 0.64; 95% CI, 0.47-0.88).
- Urgent revascularization was less frequent in the invasive group (IRR, 0.39; 95% CI, 0.25-0.62).
- However, all-cause mortality and cardiovascular mortality did not significantly differ between the two groups.
The study found that an invasive strategy conferred a gain of 276 event-free days over five years (95% CI, 151-400 days), with even greater benefits in higher-risk subgroups. Interestingly, while nearly half the participants were women, female patients in the invasive group had a higher incidence of non-obstructive coronary disease compared to men (32% vs. 14%, P = 0.001).
Conclusion
The authors concluded that, for carefully selected elderly patients with NSTE-ACS, an invasive strategy resulted in improved event-free survival compared to conservative management. These findings support the use of upfront coronary angiography and invasive management in elderly patients with significant life expectancy, as it can reduce the incidence of MI and the need for urgent revascularization.
Final Thoughts
The After Eighty trial supports the use of an invasive strategy in well-selected elderly patients with NSTE-ACS, showing clear benefits in reducing MI and urgent revascularization rates, along with improved event-free survival. However, clinicians should exercise judgment and personalize treatment decisions based on the individual patient's health status and preferences, recognizing that not all elderly patients will fit the trial’s selection criteria or benefit equally from an invasive approach.
Read the full in-depth article on Relias Media
We discuss the efficacy of invasive strategy in very old patients with non-ST elevation ACS in more detail in our full write-up on Relias Media.