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Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data.

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Title: Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data.
Authors: Kaura, Amit (AUTHOR), Sterne, Jonathan A C (AUTHOR), Trickey, Adam (AUTHOR), Abbott, Sam (AUTHOR), Mulla, Abdulrahim (AUTHOR), Glampson, Benjamin (AUTHOR), Panoulas, Vasileios (AUTHOR), Davies, Jim (AUTHOR), Woods, Kerrie (AUTHOR), Omigie, Joe (AUTHOR), Shah, Anoop D (AUTHOR), Channon, Keith M (AUTHOR), Weber, Jonathan N (AUTHOR), Thursz, Mark R (AUTHOR), Elliott, Paul (AUTHOR), Hemingway, Harry (AUTHOR), Williams, Bryan (AUTHOR), Asselbergs, Folkert W (AUTHOR), O'Sullivan, Michael (AUTHOR), Lord, Graham M (AUTHOR)
Source: Lancet. 8/29/2020, Vol. 396 Issue 10251, p623-634. 12p.
Subjects: Troponin, Survival, Research, Age distribution, Research methodology, Evaluation research, Comparative studies, Hospital care, Logistic regression analysis, Non-ST elevated myocardial infarction, Probability theory, Longitudinal method
Abstract: Background: Previous trials suggest lower long-term risk of mortality after invasive rather than non-invasive management of patients with non-ST elevation myocardial infarction (NSTEMI), but the trials excluded very elderly patients. We aimed to estimate the effect of invasive versus non-invasive management within 3 days of peak troponin concentration on the survival of patients aged 80 years or older with NSTEMI.Methods: Routine clinical data for this study were obtained from five collaborating hospitals hosting NIHR Biomedical Research Centres in the UK (all tertiary centres with emergency departments). Eligible patients were 80 years old or older when they underwent troponin measurements and were diagnosed with NSTEMI between 2010 (2008 for University College Hospital) and 2017. Propensity scores (patients' estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and compared the rate of hospital admissions for heart failure.Findings: Of the 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1500 patients had a median age of 86 (IQR 82-89) years of whom (845 [56%] received non-invasive management. During median follow-up of 3·0 (IQR 1·2-4·8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the non-invasive management group (adjusted hazard ratio 0·68, 95% CI 0·55-0·84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48-0·93).Interpretation: The survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older.Funding: NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative. [ABSTRACT FROM AUTHOR]
Copyright of Lancet is the property of Lancet and its content may not be copied or emailed to multiple sites without the copyright holder's express written permission. Additionally, content may not be used with any artificial intelligence tools or machine learning technologies. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
Database: Psychology and Behavioral Sciences Collection
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  Data: Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data.
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  Data: <searchLink fieldCode="AR" term="%22Kaura%2C+Amit%22">Kaura, Amit</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Sterne%2C+Jonathan+A+C%22">Sterne, Jonathan A C</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Trickey%2C+Adam%22">Trickey, Adam</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Abbott%2C+Sam%22">Abbott, Sam</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Mulla%2C+Abdulrahim%22">Mulla, Abdulrahim</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Glampson%2C+Benjamin%22">Glampson, Benjamin</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Panoulas%2C+Vasileios%22">Panoulas, Vasileios</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Davies%2C+Jim%22">Davies, Jim</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Woods%2C+Kerrie%22">Woods, Kerrie</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Omigie%2C+Joe%22">Omigie, Joe</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Shah%2C+Anoop+D%22">Shah, Anoop D</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Channon%2C+Keith+M%22">Channon, Keith M</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Weber%2C+Jonathan+N%22">Weber, Jonathan N</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Thursz%2C+Mark+R%22">Thursz, Mark R</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Elliott%2C+Paul%22">Elliott, Paul</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Hemingway%2C+Harry%22">Hemingway, Harry</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Williams%2C+Bryan%22">Williams, Bryan</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Asselbergs%2C+Folkert+W%22">Asselbergs, Folkert W</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22O'Sullivan%2C+Michael%22">O'Sullivan, Michael</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Lord%2C+Graham+M%22">Lord, Graham M</searchLink> (AUTHOR)
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  Data: <searchLink fieldCode="JN" term="%22Lancet%22">Lancet</searchLink>. 8/29/2020, Vol. 396 Issue 10251, p623-634. 12p.
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  Data: <searchLink fieldCode="DE" term="%22Troponin%22">Troponin</searchLink><br /><searchLink fieldCode="DE" term="%22Survival%22">Survival</searchLink><br /><searchLink fieldCode="DE" term="%22Research%22">Research</searchLink><br /><searchLink fieldCode="DE" term="%22Age+distribution%22">Age distribution</searchLink><br /><searchLink fieldCode="DE" term="%22Research+methodology%22">Research methodology</searchLink><br /><searchLink fieldCode="DE" term="%22Evaluation+research%22">Evaluation research</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+studies%22">Comparative studies</searchLink><br /><searchLink fieldCode="DE" term="%22Hospital+care%22">Hospital care</searchLink><br /><searchLink fieldCode="DE" term="%22Logistic+regression+analysis%22">Logistic regression analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Non-ST+elevated+myocardial+infarction%22">Non-ST elevated myocardial infarction</searchLink><br /><searchLink fieldCode="DE" term="%22Probability+theory%22">Probability theory</searchLink><br /><searchLink fieldCode="DE" term="%22Longitudinal+method%22">Longitudinal method</searchLink>
– Name: Abstract
  Label: Abstract
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  Data: <bold>Background: </bold>Previous trials suggest lower long-term risk of mortality after invasive rather than non-invasive management of patients with non-ST elevation myocardial infarction (NSTEMI), but the trials excluded very elderly patients. We aimed to estimate the effect of invasive versus non-invasive management within 3 days of peak troponin concentration on the survival of patients aged 80 years or older with NSTEMI.<bold>Methods: </bold>Routine clinical data for this study were obtained from five collaborating hospitals hosting NIHR Biomedical Research Centres in the UK (all tertiary centres with emergency departments). Eligible patients were 80 years old or older when they underwent troponin measurements and were diagnosed with NSTEMI between 2010 (2008 for University College Hospital) and 2017. Propensity scores (patients' estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and compared the rate of hospital admissions for heart failure.<bold>Findings: </bold>Of the 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1500 patients had a median age of 86 (IQR 82-89) years of whom (845 [56%] received non-invasive management. During median follow-up of 3·0 (IQR 1·2-4·8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the non-invasive management group (adjusted hazard ratio 0·68, 95% CI 0·55-0·84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48-0·93).<bold>Interpretation: </bold>The survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older.<bold>Funding: </bold>NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative. [ABSTRACT FROM AUTHOR]
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  Data: <i>Copyright of Lancet is the property of Lancet and its content may not be copied or emailed to multiple sites without the copyright holder's express written permission. Additionally, content may not be used with any artificial intelligence tools or machine learning technologies. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract.</i> (Copyright applies to all Abstracts.)
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        Value: 10.1016/S0140-6736(20)30930-2
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