Key Points:
- Many older patients with NSTEMI do not receive coronary angiography during their index admission due to a high concern for complications and uncertainty regarding its benefits.
- SENIOR-RITA randomized type 1 NSTEMI patients aged 75 or older to a conservative strategy of optimal medical therapy alone or an invasive strategy of optimal medical therapy plus angiography, with revascularization if indicated.
- There was no difference in the primary composite endpoint of cardiovascular death or MI at a median of 4.1 years between the two strategies, but there was a significant reduction in non-fatal MI and subsequent revascularization procedures in the invasive arm, with a low procedural complication rate of <1%.
- The relative safety and potential benefit of an invasive strategy observed in SENIOR-RITA—the largest trial to date in this population—can help inform shared decision making for elderly patients with NSTEMI.
Guidelines recommend angiography for high-risk patients with a non-ST elevation myocardial infarction (NSTEMI). However elderly patients were not included in many of the seminal trials, and both clinicians and patients may choose to forego an invasive strategy out of concern that the potential harms exceed the benefits.
On September 1st, 2024, the principal results of “SENIOR RITA: Invasive versus Conservative Strategy for Older Patients with Myocardial Infarction” were presented at ESC Congress 2024, with simultaneous publication in the New England Journal of Medicine. The purpose was to determine whether an invasive strategy is superior to a conservative strategy in reducing cardiovascular (CV) death and non-fatal MI in older NSTEMI patients.
This open-label trial randomized patients aged 75 or older presenting with type 1 NSTEMI in a 1:1 fashion to a conservative strategy of optimal medical therapy (OMT; consisting of guideline-based antiplatelet therapy, statins, ACE inhibitors, and beta-blockers) or an invasive strategy of OMT plus coronary angiography, with coronary revascularization if indicated. The primary endpoint was a composite of CV death and non-fatal MI. Secondary endpoints included the individual components of the primary composite, as well as all-cause death, subsequent coronary revascularization, and bleeding complications. Overall, 1,518 patients in England and Scotland were included. The mean age was 82.4; 45% were female, 80% were pre-frail or frail, 60% had cognitive impairment and the majority had high comorbidity indices. OMT was similar in the two groups, and 90% of the invasive arm underwent angiography and 50% underwent revascularization during the index hospitalization.
At a median follow up of 4.1 years, there was no significant difference in the primary endpoint between the two groups (25.6% in the invasive arm vs. 26.3% in the conservative arm; HR 0.94 [95% CI 0.77-1.14]). Cardiovascular death rates were similar (15.8% in the invasive arm vs. 14.2% in the conservative arm; HR 1.11 [0.86-1.44]). Non-fatal MI rates, however, were significantly lower in the invasive arm compared to the conservative arm (11.7% vs 15.0%; HR 0.75 [0.57-0.99]), as were rates of subsequent revascularization procedures (3.9% vs. 13.7%; HR 0.26 [0.17-0.39]). There was no difference in the primary outcome based on the presence of frailty or cognitive impairment, and there were no differences in all-cause death, stroke, hospitalization for heart failure, or bleeding complications. The procedural complication rate was < 1%.
Professor Vijay Kunadian of the Translational and Clinical Research Institute, Newcastle University and Freeman Hospital, Newcastle-Upon-Tyne, UK, concluded: “An invasive strategy did not reduce the primary endpoint, but we did see some benefits. Importantly, the invasive strategy appeared to be safe overall in our older patients. Including older patients in trials enables us to challenge current practice and highlights that age should not be a barrier to individualized care, including access to angiography and percutaneous coronary intervention.”