Research in context
Evidence before this study
We searched PubMed on April 10, 2015, for manuscripts published in English between Jan 1, 2000, and April 10, 2015, with the terms “non ST-elevation myocardial infarction in the elderly” and “acute coronary syndrome in the elderly”. We had no specific inclusion or exclusion criteria for the studies searched.
A meta-analysis of the FRISC II, ICTUS, and RITA-3 trials suggested that patients older than 75 years benefit from a routine invasive strategy, but data are not available for patients aged 80 years or older. Median age in these trials was less than 65 years whereas it is older in community populations. Consequently, these trials do not have adequate sample sizes to enable subgroup analysis in patients older than 80 years. The Italian Elderly Acute Coronary Syndrome study, with 196 patients older than 80 years, is the only exception, but this trial was underpowered. An early invasive strategy in selected patients aged 80 years or more with non-ST-elevation myocardial infarction (NSTEMI) or unstable angina pectoris was associated with a reduction in endpoints (a composite of myocardial infarction, stroke, death, bleeding complications, and length of hospital stay) in the 2003–10 Nationwide Inpatient Sample database and the GRACE registry. In the most cited trials, the population aged 80 years and older is under-represented or missing, making proper subanalysis of benefits and disadvantages uncertain. This difficulty explains why references targeting this population are scarce in the guidelines and also why the European Society of Cardiology, American Heart Association, and American College of Cardiology have called for trials in this age group.
Added value of this study
The After Eighty study is the first randomised controlled trial to be specifically designed for the very elderly population (aged 80 years or older) with NSTEMI and unstable angina, which are frequent causes of hospital admission in this age group. In the present randomised controlled trial, 457 patients aged 80 years or older with NSTEMI or unstable angina were randomly assigned to an invasive strategy (including early coronary angiography with immediate assessment for percutaneous coronary intervention, coronary artery bypass graft, and optimum medical treatment) or to a conservative strategy (optimum medical treatment only). The primary outcome was a composite of myocardial infarction, need for urgent revascularisation, stroke, and death. The results show that an invasive strategy is superior to a conservative one. However, a dilution of the efficacy occurred with increasing age, and for patients older than 90 years the merit of the invasive strategy was not clear. Bleeding complication rates did not differ between the two strategies.
Implications of all the available evidence
Previous randomised trials suggest an invasive strategy is beneficial after NSTEMI and unstable angina. The results from the After Eighty study support use of an invasive strategy in patients aged 80 years or older. However, a dilution of the efficacy occurred with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial.