Invasive Treatment Strategy for Older Patients with Myocardial Infarction.

IF 96.2 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL New England Journal of Medicine Pub Date : 2024-11-07 Epub Date: 2024-09-01 DOI:10.1056/NEJMoa2407791
Vijay Kunadian, Helen Mossop, Carol Shields, Michelle Bardgett, Philippa Watts, M Dawn Teare, Jonathan Pritchard, Jennifer Adams-Hall, Craig Runnett, David P Ripley, Justin Carter, Julie Quigley, Justin Cooke, David Austin, Jerry Murphy, Damian Kelly, James McGowan, Murugapathy Veerasamy, Dirk Felmeden, Hussain Contractor, Sanjay Mutgi, John Irving, Steven Lindsay, Gavin Galasko, Kelvin Lee, Ayyaz Sultan, Amardeep G Dastidar, Shazia Hussain, Iftikhar Ul Haq, Mark de Belder, Martin Denvir, Marcus Flather, Robert F Storey, David E Newby, Stuart J Pocock, Keith A A Fox
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Abstract

Background: Whether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear.

Methods: We conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis.

Results: A total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P = 0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients.

Conclusions: In older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.).

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老年心肌梗死患者的侵入性治疗策略
背景:对于患有非 ST 段抬高型心肌梗死(NSTEMI)的老年人来说,单纯的保守药物治疗策略还是药物治疗加侵入性治疗策略更有益,目前仍不清楚:我们开展了一项前瞻性、多中心、随机试验,在英国 48 个地点对 75 岁或以上的 NSTEMI 患者进行了研究。患者按 1:1 的比例被分配到采用现有最佳药物疗法的保守策略或采用冠状动脉造影术和血管再通术加现有最佳药物疗法的侵入性策略。体弱或合并症较多的患者符合条件。主要结果是心血管原因导致的死亡(心血管死亡)或非致死性心肌梗死的复合结果,以时间到事件分析法进行评估:共有1518名患者接受了随机分配,其中753名患者被分配到侵入策略组,765名患者被分配到保守策略组。患者的平均年龄为 82 岁,45% 为女性,32% 为体弱者。在中位 4.1 年的随访期间,侵入策略组有 193 名患者(25.6%)发生了主要结局事件,保守策略组有 201 名患者(26.3%)发生了主要结局事件(危险比为 0.94;95% 置信区间 [CI],0.77 至 1.14;P = 0.53)。有创策略组中有15.8%的患者发生心血管死亡,保守策略组中有14.2%的患者发生心血管死亡(危险比为1.11;95% CI为0.86至1.44)。有创策略组中有 11.7% 的患者发生了非致命性心肌梗死,保守策略组中有 15.0% 的患者发生了非致命性心肌梗死(危险比为 0.75;95% CI 为 0.57 至 0.99)。手术并发症发生率低于1%:结论:对于患有NSTEMI的老年人,在中位随访4.1年的过程中,有创策略并不会导致心血管死亡或非致死性心肌梗死(综合主要结局)的风险显著低于保守策略。(由英国心脏基金会资助;英国心脏基金会SENIOR-RITA ISRCTN注册号:ISRCTN11343602)。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
New England Journal of Medicine
New England Journal of Medicine 医学-医学:内科
CiteScore
145.40
自引率
0.60%
发文量
1839
审稿时长
1 months
期刊介绍: The New England Journal of Medicine (NEJM) stands as the foremost medical journal and website worldwide. With an impressive history spanning over two centuries, NEJM boasts a consistent publication of superb, peer-reviewed research and engaging clinical content. Our primary objective revolves around delivering high-caliber information and findings at the juncture of biomedical science and clinical practice. We strive to present this knowledge in formats that are not only comprehensible but also hold practical value, effectively influencing healthcare practices and ultimately enhancing patient outcomes.
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