NEJM 2024

Journal club August 2025

Invasive Treatment Strategy for Older Patients with Myocardial Infarction

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.)

A total of 376 patients (49.9%) in the invasive-strategy group underwent a revascularization procedure: 46.6% of the patients underwent PCI, with multivessel PCI performed in 29.9% of the patients, including 4.9% who received balloon angioplasty only, and 3.3% underwent CABG (Table 2 and Table S10).

We had assumed even in the elderly intervention did not reduce reinfarction.

Amongst this group is a good precentage with prior MI and prior PCI and previous CABG.

Might this be because we don't know the culprit lesion because these are patient with very high plaque burden? The ISCHEMIA trial was with stable patients, showing outcome relates to plaque burden, so do these very elderly patients behave more like the ISCHEMIA trial patients since it is difficult to identify the culprit lesion. Only tiny percent had CABG- the trial itself does not rule out the possibility of benefit is this subgroup that were considered candidates for CABG, that is well enough etc.