Regarding NSTEACS treatment for patients aged 80 years or older, deciding whether invasive treatment is suitable is still unclear for both patients and doctors. Age was a main predictor of adverse outcomes after ACS, and a 10-year increase in age conferred to a 70–75% increase in mortality[2, 3]. Although the high-risk population is expanding, data on invasive treatment for elderly patients 80 years or older in cardiovascular research is limited. This leads to a contradiction in treatment; that is, elderly patients with the highest risk are least likely to receive invasive treatment, which leads to the most benefits. In this retrospective analysis, we compared the effects of invasive management and noninvasive management on clinical outcomes in this population.
Data from our study showed that 59.5% of eligible patients received invasive management, and 78% of patients with NSTEMI aged 60 years or younger underwent invasive management in a previous study[4]. In this analysis, age was the most powerful factor that affected whether patients chose invasive treatment, followed by renal function (> stage 2) and malignancy. This conclusion is consistent with some previous studies[8].
Data from the study verified the evidence that invasive management can be suitable for older patients with NSTEACS[9, 10]. Compared with the noninvasive group, the invasive management group had better survival outcomes and fewer events. Due to the perioperative risks and reduced tolerance of elderly patients, medication tends to be the most chosen treatment modality for NSTEACS patients aged 80 years or older by both the patients and their doctors. In the absence of randomized trials, some registry studies have shown the benefits of invasive therapy[9, 11], and this recommendation was reinforced in this retrospective analysis. In terms of major bleeding, the two strategies did not differ, and this result was consistent with a previous study[12]; the reason may be related to the preventive use of proton pump inhibitors and clopidogrel. Therefore, the intervention could be considered a safe and feasible treatment option in elderly people aged 80 years or older. Therefore, the benefits of the intervention have not been fully realized in the clinical setting. When a patient can choose invasive or noninvasive therapy, invasive therapy might be a more beneficial strategy.
Older patients with NSTEACS often have more complex coronary anatomy than younger patients. When patients are diagnosed as having multivessel disease, the choice between target vessel reconstruction and CR is another issue that the surgeon must consider. In this study, among the patients who underwent invasive treatment, 62.6% achieved CR. There was no significant difference between CR and culprit-only PCI in terms of all-cause death, which was consistent with the result of a meta-analysis of patients aged 75 years or older with NSTEACS[13]. However, we did not observe a reduction in the incidence of adverse events between CR and culprit-only PCI. This is inconsistent with the conclusions of many previous studies[14, 15]. The underlying reason may be that the follow-up time was not long enough or because of the characteristics of the observed population. As elderly individuals aged 80 years or older increase in age, activity levels are further decreased and the corresponding coronary oxygen consumption demand is decreased. In addition, the application of antiplatelet drugs, statins and other drugs reduces the occurrence of plaque rupture, thereby reducing the probability of acute myocardial ischemia. Additionally, culprit-only PCI could avoid the decline in renal function caused by contrast agents. For future clinical decision-making, culprit-only PCI can be an option for NSTEACS patients aged 80 years or older with multiple comorbidities.