Invasive strategy for frail older patients with NSTEMI may do more harm than good

In the treatment of frail older patients with non–ST-elevation myocardial infarction (NSTEMI), an invasive strategy does not appear to provide additional benefit compared with a conservative strategy and may even contribute to an increased risk of harm in those at the highest levels of frailty, according to the secondary analysis of the SENIOR-RITA trial.

SENIOR-RITA involved patients with NSTEMI aged 75 years or older who were randomly assigned to undergo an invasive treatment strategy (ie, coronary angiography, revascularization if needed, and optimal medical therapy) or a conservative strategy (ie, optimal medical therapy only).

The present analysis included 469 patients (median age 83 years, 51.2 percent female) who met the criteria for frailty, with 231 in the invasive group and 238 in the conservative group. Frailty status was defined using the Fried frailty criteria (frail, ≥3 criteria present). The primary composite outcome was cardiovascular death or nonfatal myocardial infarction (MI).

Over a median follow-up of 4.1 years, the composite outcome occurred in 37.7 percent of patients in the invasive group vs 29.4 percent in the conservative group (hazard ratio [HR], 1.21, 95 percent confidence interval [CI], 0.88–1.67).

Further analysis showed that patients at the highest levels of frailty had a potential signal for harm with routine invasive strategy.

No significant between-group differences were observed for cardiovascular death (HR, 1.44, 95 percent CI, 0.97–2.10) and nonfatal MI (HR, 1.00, 95 percent CI, 0.61–1.63) across frailty categories.