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An early invasive approach to NSTEMI in the elderly: A double‐edged sword?

Urgent and timely revascularization is a wellestablished cornerstone of therapy in the treatment of ST elevation myocardial infarction (STEMI). However, guidelines directing therapy in non-ST segment elevation myocardial infarction (NSTEMI) are not as definitive. These guidelines recommend two treatment pathways: an early invasive strategy (EIS) and an initial conservative strategy. The EIS directs patients toward invasive diagnostic evaluation often prior to noninvasive testing, without failing medical therapy, and on a more expeditious time frame (<24 h from presentation). This strategy confers several advantages besides risk stratification alone. Percutaneous intervention of the culprit lesion reduces the need for chronic anti-anginal therapy and rehospitalizations. In addition, patients identified as having multivessel disease would gain the added mortality benefit from referral for coronary artery bypass graft surgery early. The initial conservative strategy recommends an invasive approach for those who fail medical therapy or if there is objective evidence of active ischemia on noninvasive testing. This strategy has the advantage of avoiding the risks associated with an invasive procedure. When this strategy is chosen, often noninvasive evaluation is required to assess for significant ischemia and to identify left ventricular dysfunction. Deciding which strategy to take can be done based on riskstratifying patients using risk calculators such as thrombolysis in myocardial infarction (MI) or the global registry of acute coronary events calculator [1]. In the United States, among people who died of ischemic heart disease, 83% were older than 65 years. Moreover, even though people older than 75 years only account for 6% of the US population, they represent 60% of MI-related deaths [2]. Increasing age is one of the major predictors of poorer outcomes in NSTEMI. However, despite the fact that the guidelines recommend therapeutic interventions based on risk rather than age, there appears to be widespread reluctance to use an invasive strategy in a uniform manner in the elderly population. This is likely in part, due to the fact that the elderly population is under-represented or excluded in acute coronary syndrome (ACS) clinical trials; therefore, there is limited evidence guiding treatment in this population. In this issue of Catheterization and Cardiovascular Interventions, Angeli et al. [3] present a meta-analysis of nine randomized clinical trials (RCTs) involving 9,400 patients comparing the benefit of an EIS to a selectively invasive strategy (SIS). The primary composite endpoint of MI and all-cause death was 16% in the EIS group and 18.3% in the SIS group (OR: 0.85, 95% CI: 0.76–0.95). In addition, the reduction in rehospitalization and recurrent MI was greater in the older population (>65 years) as compared to younger study populations. Moreover, the benefit was seen in both male and female subgroups. This article adds to the evidence suggesting the benefits of EIS that has been accumulating since 1999. Evidence suggests that this benefit is seen even as improvements in medical therapy and antiplatelet strategies have advanced. Although previous evidence has also suggested benefit of EIS in the elderly population, the main reason for continued reluctance seems to be due the increased risk of bleeding in the very same population, as noted by a meta-analysis that included several percutaneous coronary intervention trials (FRISC-II, TACTICS, RITA-3, VINO, and MATE). Among patients older than 75 years, EIS led to a relative reduction of 56% in death or MI at 6 months. However, this comes at a price of increasing major bleeding events from 6.5 to 16.6% [4]. Therefore, decisions regarding both medical and invasive strategies in this population are complex and must be made on an individual basis. Tailored care should be provided