acute coronary syndrome

conservative treatment

heart failure

Invasive Versus Conservative Treatment Strategy in Older Patients With Non-ST Segment Elevation Acute Coronary Syndromes: A Meta-Analysis of Randomized Controlled Trials

aged

In patients over the age of 70 who experience a heart attack, it appears that non-intervention is as good as early intervention considering the increased risk of bleeding. James W. Mold, MD, MPH

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Importance: The optimal management strategy for older patients who present with acute coronary syndrome (ACS) remains unclear due to a paucity of randomized evidence. New large and longer-term randomized data are available.

Objective: To test the association of an early invasive strategy vs a conservative strategy with clinical outcomes for patients 70 years or older who present with ACS.

Data sources: A literature search strategy was designed in collaboration with a medical librarian. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched ,with no language restrictions from inception through October 2024. Bibliographies of previous reviews and conference abstracts from major cardiovascular scientific meetings were handsearched.

Study selection: Studies were deemed eligible following review by 2 independent, masked investigators if they randomly allocated patients 70 years or older who presented with ACS to early invasive or conservative management and reported clinical end points. Observational analyses were excluded. No trials were excluded based on sample size or follow-up duration.

Data extraction and synthesis: Data were extracted independently and in triplicate. Clinical end points were pooled in meta-analyses that applied fixed-effects and random-effects modeling to calculate summary estimates for relative risks (RRs) and hazard ratios, along with their corresponding 95% CIs.

Main outcomes and measures: The prespecified primary end point was all-cause death. Secondary end points included recurrent myocardial infarction (MI), repeated coronary revascularization, major bleeding, cardiovascular death, death or MI, stroke, heart failure hospitalization, major adverse cardiac events, major adverse cardiovascular or cerebrovascular events, and length of hospital stay.

Results: The sample size-weighted mean age of participants across included trials was 82.6 years, and 46% were female. In the pooled analysis, there was no significant difference in all-cause death between the invasive and conservative strategies (RR, 1.05; 95% CI, 0.98-1.11; P = .15; I2 = 0%). An early invasive strategy was associated with a reduced risk of recurrent MI of 22% (RR, 0.78; 95% CI, 0.67-0.91; P = .001; I2 = 0%) and repeated coronary revascularization during follow-up of 57% (RR, 0.43; 95% CI, 0.30-0.60; P < .001; I2 = 33.3%). However, an invasive strategy was associated with an increased risk of major bleeding (RR, 1.60; 95% CI, 1.01-2.53; P = .05; I2 = 16.7). No differences were observed in secondary end points. Results in the non-ST-elevation ACS population were consistent with the overall findings.

Conclusions and relevance: The results of this systematic review and meta-analysis suggest that, in older patients with ACS, an early invasive strategy was not associated with reduced all-cause death compared with conservative management. An early invasive strategy was associated with reduced recurrent MI and repeated coronary revascularization during follow-up but increased risk of major bleeding. Competing risks associated with an early invasive strategy should be weighed in shared therapeutic decision-making for older patients with ACS.

Author/s:

Rohin K Reddy, David Koeckerling, Christian Eichhorn, Yasser Jamil, Maddalena Ardissino, Volker Braun, Haitham Abu Sharar, Norbert Frey, James P Howard, Yousif Ahmad

Invasive Versus Conservative Treatment Strategy in Older Patients With Non-ST Segment Elevation Acute Coronary Syndromes: A Meta-Analysis of Randomized Controlled Trials

Alex Haga — Mon, 31 Mar 2025 13:51:29 +0000

Date Added:

March 31, 2025

Journal/Publication:

J Am Geriatr Soc .

Publication Date:

March 26, 2025

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1111/jgs.19447

Keywords

NSTEMI

Conservative treatment

invasive treatment

revascularization

unstable angina pectoris

PMID (1):

40135822

MeSH

conservative treatment

Association of Influenza Vaccination With Cardiovascular Risk: A Meta-analysis

Revascularization may reduce subsequent MI and invasive procedures but not mortality compared to conservative care in older patients following non-ST elevation MI. James W. Mold, MD, MPH

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Background
Non-ST segment elevation acute coronary syndromes (NSTE-ACS) are a common cause of hospital admission in older patients. Our study aims to synthesize the available evidence from randomized controlled trials (RCTs) to compare clinical outcomes with invasive versus conservative medical management in this population.

Methods
A literature search of online databases including PubMed/MEDLINE, Embase, and the Cochrane Library was conducted from inception to September 1, 2024. The search aimed to identify RCTs that reported clinical outcomes with invasive versus conservative strategies in older patients (≥ 70 years) with NSTE-ACS. The risk ratios (RRs) were used as summary estimates.

Results
Seven RCTs with 2998 patients were included; 1490 patients in the invasive group and 1508 patients in the conservatively managed group. The pooled analysis demonstrated no statistically significant difference between the two strategies for the risk of all-cause death (RR: 1.03, 95% CI: 0.92–1.15), cardiovascular death (RR: 1.04, 95% CI: 0.82–1.33), stroke (RR: 0.78, 95% CI: 0.53–1.15), and major bleeding (RR: 1.23, 95% CI: 0.90–1.69). However, the invasive strategy was associated with a significantly reduced risk of myocardial infarction (RR: 0.74, 95% CI: 0.57–0.96) and unplanned revascularization (RR: 0.29, 95% CI: 0.21–0.40) compared to the conservative strategy.

Conclusion
In older patients with NSTE-ACS, an invasive strategy reduces the risk of repeat myocardial infarction and unplanned revascularization without a significant increase in stroke or major bleeding. There was no associated reduction in all-cause or cardiovascular mortality with the invasive strategy compared to conservative management.

Author/s:

Mushood Ahmed, Areeba Ahsan, Aimen Shafiq, Tallal Mushtaq Hashmi

Association of Influenza Vaccination With Cardiovascular Risk: A Meta-analysis

Saige Blanchard — Tue, 10 May 2022 05:00:00 +0000

Date Added:

May 10, 2022

Journal/Publication:

JAMA Network Open

Publisher:

JAMA Network Open

Publication Date:

April 29, 2022

Issue:

Volume:

Pages:

1-9

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2022.8873

Keywords

PMID (1):

35486404

MeSH

influenza vaccines

Final Report of a Trial of Intensive versus Standard Blood-Pressure Control

Odds Ratio

COVID-19

follow-up studies

It appears that the influenza vaccine somehow reduces the risk of cardiovascular events over the subsequent year by almost 2%, which is about as effective as lowering blood pressure in older people. At the very least, it could be another way to convince people to get immunized. James W. Mold, MD, MPH

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Importance: Influenza infection is associated with increased cardiovascular hospitalization and mortality. Our prior systematic review and meta-analysis hypothesized that influenza vaccination was associated with a lower risk of cardiovascular events.

Objective: To evaluate, via an updated meta-analysis, if seasonal influenza vaccination is associated with a lower risk of fatal and nonfatal cardiovascular events and assess whether the newest cardiovascular outcome trial results are consistent with prior findings.

Data sources: A previously published meta-analysis of randomized controlled trials (RCTs) and a large 2021 cardiovascular outcome trial.

Study selection: Studies with RCTs published between 2000 and 2021 that randomized participants to either influenza vaccine or placebo/control. Eligible participants were inpatients and outpatients recruited for international multicenter RCTs and randomized to receive either influenza vaccine or placebo/control.

Data extraction and synthesis: PRISMA guidelines were followed in the extraction of study details, and risk of bias was assessed using the Cochrane Collaboration tool. Trial quality was evaluated using Cochrane criteria. Data were analyzed January 2020 and December 2021.

Main outcomes and measures: Random-effects Mantel-Haenszel risk ratios (RRs) and 95% CIs were derived for a composite of major adverse cardiovascular events and cardiovascular mortality within 12 months of follow-up. Where available, analyses were stratified by patients with and without recent acute coronary syndrome (ACS) within 1 year of randomization.

Results: Six published RCTs comprising a total of 9001 patients were included (mean age, 65.5 years; 42.5% women; 52.3% with a cardiac history). Overall, influenza vaccine was associated with a lower risk of composite cardiovascular events (3.6% vs 5.4%; RR, 0.66; 95% CI, 0.53-0.83; P < .001). A treatment interaction was detected between patients with recent ACS (RR, 0.55; 95% CI, 0.41-0.75) and without recent ACS (RR, 1.00; 95% CI, 0.68-1.47) (P for interaction = .02). For cardiovascular mortality, a treatment interaction was also detected between patients with recent ACS (RR, 0.44; 95% CI, 0.23-0.85) and without recent ACS (RR, 1.45; 95% CI, 0.84-2.50) (P for interaction = .006), while 1.7% of vaccine recipients died of cardiovascular causes compared with 2.5% of placebo or control recipients (RR, 0.74; 95% CI, 0.42-1.30; P = .29).

Conclusions and relevance: In this study, receipt of influenza vaccination was associated with a 34% lower risk of major adverse cardiovascular events, and individuals with recent ACS had a 45% lower risk. Given influenza poses a threat to population health during the COVID-19 pandemic, it is integral to counsel high-risk patients on the cardiovascular benefits of influenza vaccination.

Author/s:

Behrouzi, B., Bhatt, D. L., Cannon, C. P., Vardeny, O., Lee, D. S., Solomon, S. D., Udell, J. A.

Final Report of a Trial of Intensive versus Standard Blood-Pressure Control

Saige Blanchard — Fri, 21 May 2021 05:00:00 +0000

Date Added:

May 21, 2021

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

May 20, 2021

Issue:

Volume:

384

Pages:

1921-1930

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa1901281

Keywords

PMID (1):

34010531

MeSH

blood-pressure

cardiovascular diseases

heart failure

hypotension

Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation

In patients at high risk for cardiovascular events, intensive BP control (target <120 systolic) reduced the rate of adverse CV events (CAD events, CVA, CHF, or death) by 0.63% per year. Serious adverse events of hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were significantly more frequent in the intensive-treatment group. James W. Mold, MD, MPH

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Background: In a previously reported randomized trial of standard and intensive systolic blood-pressure control, data on some outcome events had yet to be adjudicated and post-trial follow-up data had not yet been collected.

Methods: We randomly assigned 9361 participants who were at increased risk for cardiovascular disease but did not have diabetes or previous stroke to adhere to an intensive treatment target (systolic blood pressure, <120 mm Hg) or a standard treatment target (systolic blood pressure, <140 mm Hg). The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, acute decompensated heart failure, or death from cardiovascular causes. Additional primary outcome events occurring through the end of the intervention period (August 20, 2015) were adjudicated after data lock for the primary analysis. We also analyzed post-trial observational follow-up data through July 29, 2016.

Results: At a median of 3.33 years of follow-up, the rate of the primary outcome and all-cause mortality during the trial were significantly lower in the intensive-treatment group than in the standard-treatment group (rate of the primary outcome, 1.77% per year vs. 2.40% per year; hazard ratio, 0.73; 95% confidence interval [CI], 0.63 to 0.86; all-cause mortality, 1.06% per year vs. 1.41% per year; hazard ratio, 0.75; 95% CI, 0.61 to 0.92). Serious adverse events of hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were significantly more frequent in the intensive-treatment group. When trial and post-trial follow-up data were combined (3.88 years in total), similar patterns were found for treatment benefit and adverse events; however, rates of heart failure no longer differed between the groups.

Conclusions: Among patients who were at increased cardiovascular risk, targeting a systolic blood pressure of less than 120 mm Hg resulted in lower rates of major adverse cardiovascular events and lower all-cause mortality than targeting a systolic blood pressure of less than 140 mm Hg, both during receipt of the randomly assigned therapy and after the trial. Rates of some adverse events were higher in the intensive-treatment group. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062.).

Author/s:

Lewis, C. E., Fine, L. J., Beddhu, S., Cheung, A. K., Cushman, W. C., Cutler, J. A., Evans, G. W., Johnson, K. C., Kitzman, D. W., Oparil, S., Rahman, M., Reboussin, D. M., Rocco, M. V., Sink, K, M., Snyder, J. K., Whelton, P. K., Williamson, J. D., Wright Jr., J. T., Ambrosius, W. T.

Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation

John Bayhi — Fri, 28 Feb 2020 14:21:39 +0000

Date Added:

February 28, 2020

Journal/Publication:

JAMA Network Open

Publisher:

American Medical Association

Publication Date:

February 5, 2020

Issue:

Volume:

Pages:

e200107

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2020.0107

Keywords

PMID (1):

32101311

MeSH

Platelet Aggregation Inhibitors

coronary artery disease

hemorrhage

Registries

The results of this cohort study suggest that for patients with atrial fibrillation, adding an antiplatelet agent to an oral anticoagulant results in more strokes and bleeding and does not protect them from MI. James W. Mold, MD, MPH

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IMPORTANCE:

Patients with nonvalvular atrial fibrillation at risk of stroke should receive oral anticoagulants (OAC). However, approximately 1 in 8 patients in the Global Anticoagulant Registry in the Field (GARFIELD-AF) registry are treated with antiplatelet (AP) drugs in addition to OAC, with or without documented vascular disease or other indications for AP therapy.

OBJECTIVE:

To investigate baseline characteristics and outcomes of patients who were prescribed OAC plus AP therapy vs OAC alone.

DESIGN, SETTING, AND PARTICIPANTS:

Prospective cohort study of the GARFIELD-AF registry, an international, multicenter, observational study of adults aged 18 years and older with recently diagnosed nonvalvular atrial fibrillation and at least 1 risk factor for stroke enrolled between March 2010 and August 2016. Data were extracted for analysis in October 2017 and analyzed from April 2018 to June 2019.

EXPOSURE:

Participants received either OAC plus AP or OAC alone.

MAIN OUTCOMES AND MEASURES:

Clinical outcomes were measured over 3 and 12 months. Outcomes were adjusted for 40 covariates, including baseline conditions and medications.

RESULTS:

A total of 24 436 patients (13 438 [55.0%] male; median [interquartile range] age, 71 [64-78] years) were analyzed. Among eligible patients, those receiving OAC plus AP therapy had a greater prevalence of cardiovascular indications for AP, including acute coronary syndromes (22.0% vs 4.3%), coronary artery disease (39.1% vs 9.8%), and carotid occlusive disease (4.8% vs 2.0%). Over 1 year, patients treated with OAC plus AP had significantly higher incidence rates of stroke (adjusted hazard ratio [aHR], 1.49; 95% CI, 1.01-2.20) and any bleeding event (aHR, 1.41; 95% CI, 1.17-1.70) than those treated with OAC alone. These patients did not show evidence of reduced all-cause mortality (aHR, 1.22; 95% CI, 0.98-1.51). Risk of acute coronary syndrome was not reduced in patients taking OAC plus AP compared with OAC alone (aHR, 1.16; 95% CI, 0.70-1.94). Patients treated with OAC plus AP also had higher rates of all clinical outcomes than those treated with OAC alone over the short term (3 months).

CONCLUSIONS AND RELEVANCE:

This study challenges the practice of coprescribing OAC plus AP unless there is a clear indication for adding AP to OAC therapy in newly diagnosed atrial fibrillation.

Author/s:

Fox, KAA, Velentgas, P, Camm, AJ, Bassand, JP, Fitzmaurice, DA, Gersh, BJ, Goldhaber, SZ, Goto, S, Haas, S, Misselwitz, F, Pieper, KS, Turpie, AGG, Verhegut, FWA, Dabrowski, E, Luo, K, Gibbs, L, Kakkar, AK, GARFIELD-AF Investigators

Preoperative Cardiac Risk Assessment

John Bayhi — Thu, 27 Feb 2020 15:22:21 +0000

Date Added:

February 27, 2020

Journal/Publication:

Mayo Clinic Proceedings

Publisher:

Elsevier B.V. / Mayo Foundation for Medical Education and Research

Publication Date:

February 24, 2020

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2019.08.013

Keywords

cardiac

preoperative assessment

MeSH

Coronary Microvascular Dysfunction Causing Cardiac Ischemia in Women

Cost-Benefit Analysis

This is a review of the latest recommendations regarding the cardiac assessment of patients needing surgery. James W. Mold, MD, MPH

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Major adverse cardiac events are common causes of perioperative mortality and major morbidity. Preventing these complications requires thorough preoperative risk assessment and postoperative monitoring of at-risk patients. Major guidelines recommend assessment based on a validated risk calculator that incorporates patient- and procedure-specific factors. American and European guidelines define when stress testing is needed on the basis of functional capacity assessment. Favoring cost-effectiveness, Canadian guidelines instead recommend obtaining brain natriuretic peptide or N-terminal prohormone of brain natriuretic peptide levels to guide postoperative screening for myocardial injury or infarction. When conditions such as acute coronary syndrome, severe pulmonary hypertension, and decompensated heart failure are identified, nonemergent surgery should be postponed until the condition is appropriately managed. There is an evolving role of biomarkers and myocardial injury after noncardiac surgery to enhance risk stratification, but the effect of interventions guided by these strategies is unclear.

Author/s:

Raslau, D, Bierle, DM, Stephenson, CR, Mikhail, MA, Kebede, EB, Mauck, KF

Coronary Microvascular Dysfunction Causing Cardiac Ischemia in Women

John Bayhi — Wed, 20 Nov 2019 20:21:13 +0000

Date Added:

November 20, 2019

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

November 18, 2019

URL:

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2019.15736

Keywords

coronary microvascular dysfunction

CMD

obstructive coronary artery disease

cardiac ischemia

females

angina

PMID (1):

31738820

MeSH

coronary artery disease

Coronary Angiography

A Randomized Trial of Intensive versus Standard Blood-Pressure Contro

Exercise Tolerance

Diagnostic Tests

routine

cardiovascular diseases

Humans

female

Angina Pectoris

This is a concise summary of coronary microvascular dysfunction as a cause of angina and infarction in women, a relatively common phenomenon. We are also posting an audiotaped summary of this information separately. James W. Mold, MD, MPH

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Two-thirds of women who present with persistent symptoms and clinical signs of ischemia have no evidence of obstructive coronary artery disease (INOCA) on angiography. Cardiac ischemia can be manifested by chest discomfort, shortness of breath, decreased exercise tolerance, and ST-segment or imaging abnormalities at rest or with stress. Although women with a clinical presentation suggesting ischemic heart disease are often reassured after having a “normal” angiogram that their symptoms are not likely cardiac in etiology, 1 in 13 of these women die from a cardiac cause within 10 years of the angiographic evaluation, and the most frequent adverse cardiac event is hospitalization for heart failure with preserved ejection fraction with an observed 10-fold higher rate compared with asymptomatic women (3.3% vs 0.3%). For these women with INOCA, clinicians should consider the important, yet often overlooked, diagnosis of coronary microvascular dysfunction (CMD)—a small vessel disorder that confers an adverse prognosis in women for which there are available and continuously evolving diagnostic and treatment strategies.

Author/s:

Wei, J, Cheng, S, Merz, CNB

A Randomized Trial of Intensive versus Standard Blood-Pressure Control

Tracy Ashby — Fri, 22 Feb 2019 06:00:00 +0000

Date Added:

February 22, 2019

Journal/Publication:

The New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

November 26, 2015

Issue:

Volume:

373

Pages:

2103-16

URL:

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/nejmoa1511939

Keywords

blood pressure

diabetes

cardiovascular disease

risk factors

PMID (1):

26551272

MeSH

blood pressure

diabetes mellitus

cardiovascular diseases