Acute coronary syndromes: Patients 80 years and older would benefit from aggressive treatment

The study focused on treatment approaches for older patients with non ST-elevation myocardial infarction (NSTEMI, a type of heart attack that is milder in the acute phase but has a poor prognosis after six months or more) or the closely-related condition unstable angina. Both conditions are caused by the buildup of plaque in the heart's arteries.

In the study, patients 80 years and older who received invasive procedures that are typically offered to younger patients to evaluate and correct narrowed arteries had a 47 percent reduction in the study's primary endpoint, a combined measure of subsequent heart attacks, urgent revascularization procedures, stroke and death, as compared to similar patients who were treated using a more conservative approach.

"Because people over 80 are underrepresented in clinical trials, they are less likely to receive treatment according to guidelines," said Nicolai Tegn, M.D., a cardiologist at Rikshospitalet Oslo University Hospital in Norway and the study's lead author. "Our study, which directly targets the over-80 population, is the first to demonstrate that a more invasive strategy results in better outcomes in these patients. I believe our study provides a sufficient basis to recommend an invasive approach."

The study included 458 patients who were treated for NSTEMI or unstable angina at 16 health centers in Norway. Patients were randomly assigned to receive one of two treatment approaches. Half received a conservative approach, which included medications as needed but no invasive interventions. The other half underwent coronary angiography, a test in which a catheter is threaded into the arteries of the heart to release a dye that makes the extent of plaque buildup visible in an X-ray. Based on the results of this test, doctors referred patients for balloon angioplasty and/or stenting in which plaque blocking the arteries is pushed aside, heart bypass surgery in which narrowed coronary arteries are replaced by arteries grafted from elsewhere in the body, or non-invasive treatments, such as drugs.

Of the 225 patients receiving coronary angiography, 48 percent were subsequently treated with angioplasty or stenting and 3 percent were treated with bypass surgery. In a median follow-up time of 18 months, the group receiving coronary angiography showed a 47 percent reduction in the study's primary endpoint--a composite of heart attack, urgent revascularization procedures, stroke and death. The study did not show significant differences in the secondary endpoint (death from any cause) or in the risk of bleeding complications.

According to U.S. life expectancy statistics, a person who reaches age 80 can expect to live an average of 8.2 years (in men) and 9.7 years (in women). "The '80-plus' population is an extremely heterogeneous group, ranging from healthy individuals to people with severe illness," Tegn said. "The fact that many 80-year-olds have nearly a decade of life ahead of them makes these results particularly noteworthy."

Acute coronary syndromes become more common with age. It is estimated that as many as four out of five Americans over age 80 have at least one of a variety of conditions related to the buildup of plaque in the heart's arteries. NSTEMI and unstable angina are often managed with a combination of medications, lifestyle changes and dietary changes in older people. Coronary angiography testing, stenting and bypass surgery are typically offered less often for the elderly than for younger patients, though practices vary depending on physician preference and clinic capabilities.

The researchers will continue to track patients' outcomes over the coming years.