Invasive versus Conventional Management of Elderly Patients with Acute Coronary Artery Disease: Which Is Better?

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The summary below is from the full report titled "The Effect of Management Strategy on Clinical Outcome for Elderly Patients with Non–ST-Segment Elevation Acute Coronary Syndromes." It is in the 3 August 2004 issue of Annals of Internal Medicine (volume 141, pages 186-195). The authors are R.G. Bach, C.P. Cannon, W.S. Weintraub, P.M. DiBattiste, L.A. Demopoulos, H.V. Anderson, P.T. DeLucca, E.M. Mahoney, S.A. Murphy, and E. Braunwald.

What is the problem and what is known about it so far?

Signs of acute coronary artery disease lead to nearly 1.5 million hospital admissions each year in the United States. These patients have either angina (chest pain) or myocardial infarction (MI), which is commonly called a heart attack. At the hospital, they routinely receive medical treatments, including blood thinners to prevent blood clots. Doctors may choose conservative management, which means simply watching the patient closely and performing a stress test, or an early invasive approach, which calls for angiography shortly after admission. This x-ray examination shows whether there are significant blockages in the coronary arteries. If necessary, coronary intervention or surgery can be done to restore adequate blood flow to the heart wall. A majority of patients are 65 years of age or older. They tend to have invasive treatment less often than younger patients. Whether invasive measures improve the outlook for elderly patients remains uncertain.

Why did the researchers do this particular study?

To learn whether clinical outcomes in patients with acute coronary artery disease depend on age and management strategy.

Who was studied?

2220 patients at 169 hospitals in 9 countries who had acute symptoms of coronary artery disease. They included 962 patients (43%) 65 years of age and older.

How was the study done?

The researchers followed patients from the time of hospital admission. Assignment to conservative management or early invasive treatment was on a random basis. Patients managed invasively had coronary angiography 4 to 48 hours after admission. Follow-up after 30 days and 6 months compared rates of death and nonfatal MI according to age and type of treatment. The researchers also kept track of strokes and bleeding.

What did the researchers find?

After 6 months of follow-up, patients 65 years of age and older were much more likely than younger patients to die or have an MI. Although they made up less than 45% of the study group, they accounted for 71% of all deaths and 53% of MIs. Within this age group, patients treated invasively had a 39% reduction in the combined rate of death and nonfatal MI after 6 months. The difference between the invasive and conventional treatment groups was even greater in patients 75 years of age and older. In this age group, invasive treatment correlated with a 56% reduction in death or MI at 6 months. Invasive treatment also provided better outcomes in patients younger than 65 years of age, but not to a significant degree. In patients 75 years of age and older, invasive treatment more than doubled the risk for major bleeding.

What were the limitations of the study?

The study excluded patients with other serious illnesses. For this reason, those studied may have been healthier than many patients with acute coronary artery disease.

What are the implications of the study?

Routine invasive management of elderly patients with acute symptoms of coronary artery disease can prevent many nonfatal MIs and deaths. Patients older than 75 years of age, however, are at increased risk for major bleeding.