Effects of routine invasive management on reinfarction risk in older adults with frailty and non-ST-segment elevation myocardial infarction: a subanalysis of a randomised clinical trial
- PMID: 39922692
- DOI: 10.1136/heartjnl-2024-325254
Effects of routine invasive management on reinfarction risk in older adults with frailty and non-ST-segment elevation myocardial infarction: a subanalysis of a randomised clinical trial
Abstract
Background: Clinical trials and meta-analyses indicate a reduced reinfarction risk with invasive management in older patients with non-ST-segment elevation myocardial infarction (NSTEMI). This study investigated whether similar benefits might be observed in frail patients.
Methods: The coMOrbilidades Síndrome Coronario Agudo - FRAIL (MOSCA-FRAIL) trial included 167 adults aged ≥70 years with frailty (Clinical Frailty Scale ≥4 points) and NSTEMI, who were randomised to invasive (n=84) or conservative (n=83) strategy during the index hospitalisation. The primary end point of this subanalysis was reinfarction, considering all-cause mortality as a competing event, at a 3-year median follow-up. The time to first reinfarction and all reinfarctions (first and recurrent) were considered. The substudy was not prespecified.
Results: The total number of deaths (93, 56%) exceeded that of first reinfarctions (32, 19%). Invasive treatment did not influence the reinfarction risk when accounting for death as a competing risk (subdistribution HR=0.87, 95% CI 0.54 to 1.40, p=0.56). An initially increased mortality risk with invasive management (significant between days 131 and 175) shifted to a lower mortality risk over time. A total of 45 reinfarctions (first and recurrent) were observed. The longitudinal trajectories corroborated that the invasive strategy did not reduce the risk of reinfarction over time (p=0.72). However, mortality followed a biphasic pattern, with higher mortality in the invasive group during the first 6 months and a reduction between 9 months and 3 years (p=0.05 for the entire time-dependent trajectory). The win ratio for the invasive strategy versus the conservative strategy was 1.08 (95% CI 0.72 to 1.63, p=0.70).
Conclusions: In older adults with frailty and NSTEMI, routine invasive management did not reduce the reinfarction risk at a 3-year follow-up. The high all-cause mortality associated with frailty may limit the impact of invasive management. Due to the limited sample size and risk for type II error, these findings should be considered hypothesis-generating.
Trial registration number: NCT03208153.
Keywords: acute coronary syndrome.
© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.
Conflict of interest statement
Competing interests: JS reported receiving payments for presentations from Boston Scientific Corporation and Abbott Vascular outside the submitted work. HB reported receiving grant funding from the European Union, Instituto de Salud Carlos III, Sociedad Española de Cardiología, Boehringer Ingelheim and Janssen Global Services, and personal fees from AstraZeneca, Novartis, Novo Nordisk and Organon & Co outside the submitted work. FM reported receiving grant funding from Bayer, Grupo Ferrer Internacional and Boehringer-Ingelheim; support for meetings from Esteve and serving on the advisory board for the Atrial Fibrillation Network. MSF reported receiving conference fees from Amgen, Boehringer Ingelheim and AstraZeneca outside the submitted work. JN reported receiving personal fees from Alleviant Medical, AstraZeneca, Boehringer Ingelheim, Novartis, NovoNordisk Pfizer and Laboratorios Farmaceuticos Rovi outside the submitted work. No other disclosures were reported.
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