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The Italian Elderly ACS study: Early aggressive versus initially conservative strategy in elderly patients with non-ST- elevation acute coronary syndrome: the Italian Elderly ACS randomised trial ( ID: NCT00510185)

Acute Coronary Syndromes (ACS)

By Stefano Savonitto (Italy)

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List of Authors:
Stefano Savonitto, Ernesto Murena, Roberto Antonicelli, Claudio Cavallini, A. Sonia Petronio, Alice Sacco, Giuseppe Steffenino, Nuccia Morici, M. Cristina Jori, Stefano De Servi


Aim: Elderly patients represent a third of hospital admissions for acute coronary syndromes without ST-segment elevation (NSTEACS), but they have been scarcely represented in clinical trials comparing an early invasive with an initially conservative approach. Thus, since elderly patients are more susceptible to complications due to invasive procedures and aggressive antithrombotic treatments, the benefit of early intervention is uncertain.

Methods: We randomly assigned 313 patients of age >75 years (mean 81.8 years, 50% women) with NSTEACS, who had had ischemic symptoms <48 hours before enrolment, to an early invasive strategy (coronary angiography and early revascularization within 48 hours) or an initially conservative strategy (coronary angiography and revascularization only in the case of recurrent ischemia, myocardial infarction or heart failure). The primary end point was a composite of death, nonfatal myocardial infarction, disabling stroke and rehospitalization for cardiovascular causes or severe bleeding within one year after randomization. This study is registered with, number 00510185.

Findings: Eighty-eight percent of the patients in the early aggressive group underwent coronary angiography (55% revascularization) during index admission, compared to 29% (23% revascularization) in the initially conservative group. The primary outcome occurred in 43 patients (27.9%) in the early invasive group compared to 55 (34.6%) in the initially conservative group (HR 0.80; 95% CI 0.53-1.19; log rank P= 0.26).
The rates of mortality (HR 0.87; CI 0.49 – 1.56; log rank P=0.65), myocardial infarction (HR 0.67; CI 0.33 – 1.36. log rank P=0.27) and rehospitalization (HR 0.81; CI 0.45-1.46) were non significantly lower in the early invasive group. Patients with elevated troponin levels on admission experienced a significant reduction in the primary endpoint (HR 0.43; 95% CI 0.23-0.80; p=0.015), whereas no effect was observed in those with normal troponin levels (HR 1.67; 95% CI 0.75-3.70; p=0.24); P value for interaction 0.03.

Conclusion: In the whole population of elderly patients with NSTEACS, a systematic early invasive approach does not confer significant clinical advantage compared to an initially conservative approach with angiography and revascularization only in the case of recurrent ischemia. Significant benefits are confined to patients with elevated troponin levels on admission.




Clinical Registry Highlight II - Interventions and devices

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.