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Elderly may benefit from more invasive treatment: large seven-year study
Elderly patients suffering the most common type of heart
attack may benefit from more invasive treatment, research
has shown. The study draws on data captured over seven
years from 1 500 patients aged 80 years or over. It was
conducted by researchers from the National Institute of
Health Research Health Informatics Collaborative (NIHR-
HIC), led by Imperial College Healthcare NHS Trust and
Imperial College London.
The research looks at elderly patients admitted to hospital
with a non-ST-segment elevated myocardial infarction
(NSTEMI). It found patients who underwent invasive
treatment with a coronary angiogram, followed up with
bypass surgery or coronary stenting as appropriate, had higher
survival rates than those who were treated with medication
alone. Patients who had coronary angiograms were also less
likely to be re-admitted to hospital with a second heart attack
or heart failure.
Coronary angiograms are specialist X-rays to identify
blockages in the blood supply to the heart. They can help a
clinician determine the cause of an NSTEMI and decide on
effective treatment, such as increasing blood flow through a
coronary stent or bypass grafting.
Previous trials have shown increased survival rates in
younger patients with NSTEMI following invasive treatment,
but there has been conflicting evidence as to whether these
benefits extend into patients over 80 years. Only 38% of
NSTEMI patients in this older age group currently receive
invasive treatment, compared to 78% of the under 60 years.
Dr Amit Kaura, lead author of the research, British
Heart Foundation clinical research fellow and NIHR clinical
research fellow with the National Heart and Lung Institute at
Imperial College London explained: ‘Because there has been
no clear consensus on how best to manage elderly patients
with this type of heart attack, many doctors have erred on
the side of caution, not wanting to risk complications in their
more vulnerable patients. These results show they can now
be more confident of the benefits that invasive treatment can
bring for this group.’
The study, funded by the NIHR Imperial Biomedical
Research Centre, identified just under 2 000 patients aged
over 80 years who were diagnosed with an NSTEMI at five
hospitals between 2010 and 2017. To ensure the robustness
of the study, the researchers used sophisticated statistical
techniques to apply the kind of criteria used in a clinical trial,
to determine which of these patients would be included in the
analysis. In total, 1 500 patients were included, with just over
half having invasive treatment. After five years, 31% of those
in the invasive treatment group had died, compared to 61%
in the non-invasive group.
The team estimates that if all patients had received
invasive treatment, just 36% would have died, compared to
55% if all had received non-invasive treatment. These figures
take into account over 70 variables that might have affected
prognosis, such as other medical conditions.
The analysis also showed that patients were at no greater
risk of stroke or bleeding if they received invasive treatment,
as there were similar rates across both groups. Patients who
had invasive treatment were also a third less likely to be
re-admitted to hospital for heart failure or heart attack.
Kaura said: ‘The gold standard is to base treatment
decisions on evidence from randomised control trials, but
that doesn’t yet exist for this group of patients. In the interim,
we’ve done the next best thing, by looking at retrospective
data gathered from these five large hospitals and using it
like a clinical trial. The results are clear: clinicians should
positively consider invasive management for any patients
over 80 diagnosed with an NSTEMI.’
The data used in the study was gathered through the
National Institute for Health Research Health Informatics
Collaborative (NIHR-HIC), which involves: Imperial College
Healthcare NHS Trust, Oxford University Hospitals NHS
Foundation Trust, University College London Hospitals NHS
Foundation Trust, King’s College Hospital NHS Foundation
Trust and Guy’s and St Thomas’ NHS Foundation Trust.
Source:
Medical Brief 2020