Dr. Masoodi raises 2 points about our analysis of outcome according to age among patients with non–ST-segment elevation acute coronary syndromes who were randomly assigned to early invasive versus conservative management. The first pertains to the lack of data on cognitive status of trial participants. While cognitive status was not specifically quantified among the baseline patient characteristics, according to the protocol, patients included in the trial needed to be considered candidates for coronary angiography and revascularization, and we excluded patients who had any "clinically important neurologic disorder" or who were unable to provide informed consent. It is thus likely that patients with significant cognitive impairment would have been excluded, appropriately, from the trial. We agree that cognitive status should be an important consideration when recommending management for any patient with a coronary syndrome but would caution that degrees of cognitive impairment vary widely and that the related management decisions remain largely subjective and challenging.

Dr. Masoodi's second observation is that age 65 years is not considered elderly in everyday life. Although it is hard to argue with that perspective, 65 years of age has served as a milestone for many previous studies of age-related outcomes, and this can allow for comparison of treatment effects across trials. For example, when our results are combined with those from the TIMI (Thrombolysis in Myocardial Infarction) IIIB trial (1) and the FRISC (Fast Revascularisation during InStability in Coronary artery disease) II trial (2, 3), data are available for 2724 patients age 65 years or older and 3422 patients younger than 65 years of age who were randomly assigned to a management strategy. The invasive strategy, when compared with conservative management, resulted in a relative reduction in death or myocardial infarction at 6 to 12 months of 37.5% (10.7% vs. 16.8%; P < 0.001) for the older patients but only 1.4% (8.2% vs. 8.4%; P = 0.90) for the younger patients. Among the 2249 patients from the FRISC II (2, 3) and TACTICS-TIMI 18 (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy–Thrombolysis in Myocardial Infarction) trial (as reported in our study) who were age 65 years or older, allocation to early invasive management was associated with 27.5% fewer deaths at 6 to 12 months (4.2% vs. 5.8%; P = 0.099).

We recognize that in an era of increasing life expectancy, it is arbitrary and nonphysiologic to call a specific age "elderly." For that reason, we extended previous observations by including an analysis of age ranges from younger than age 55 years to older than age 75 years. We found that among the 278 patients in our trial who were in the latter age group, random assignment to a routine early invasive strategy resulted in 42% fewer occurrences of death, myocardial infarction, or rehospitalization for acute coronary syndromes (20.1% vs. 30.2%; P = 0.05). We also found a 33% lower—albeit nonsignificant—mortality rate (7.9% vs. 10.1%; P > 0.2) at 6 months. Although we expect that lower rates of the most common comorbid events in these elderly patients, namely recurrent myocardial infarctions and rehospitalizations for unstable ischemia, would translate into improved quality of life, a more detailed assessment of the effect of management strategy on functional status in the elderly is needed.