Coronary interventions

Revascularisation or medical therapy in elderly patients with acute anginal syndromes: the RINCAL randomised trial

EuroIntervention 2021;17:67-74. DOI: 10.4244/EIJ-D-20-00975

Adam de Belder
Adam de Belder1, MD; Aung Myat1,2, MD; Jonathan Blaxill3, MRCP; Peter Haworth4, MRCP; Peter D. O'Kane5, MD; Robert Hatrick6, MD; Rajesh K. Aggarwal7, MD; Andrew Davie8, MD; William Smith9, PhD; Robert Gerber10, PhD; Jonathan Byrne11, MD; Dawn Adamson12, PhD; Fraser Witherow13, MD; Osama Alsanjari1, MRCP; Juliet Wright2, MD; Derek R. Robinson14, DPhil; David Hildick-Smith1, MD
1. Sussex Cardiac Centre, Brighton, United Kingdom; 2. Brighton and Sussex Medical School, Brighton, United Kingdom; 3. Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; 4. Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; 5. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, United Kingdom; 6. Western Sussex Hospitals NHS Foundation Trust, Worthing, United Kingdom; 7. Essex Cardiothoracic Centre, Basildon, United Kingdom; 8. Golden Jubilee National Hospital and Queen Elizabeth University Hospital, Glasgow, United Kingdom; 9. Trent Cardiac Centre, Nottingham, United Kingdom; 10. East Sussex Healthcare NHS Trust, Hastings, United Kingdom; 11. King’s College Hospital NHS Foundation Trust, London, United Kingdom; 12. University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom; 13. Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom; 14. University of Sussex, Brighton, United Kingdom

Background: Historically the elderly have been under-represented in non-ST-elevation myocardial infarction (NSTEMI) management trials.

Aims: The aim of this trial was to demonstrate that an intervention-guided strategy is superior to optimal medical therapy (OMT) alone for treating NSTEMI in elderly individuals.

Methods: Patients (≥80 years, chest pain, ischaemic ECG, and elevated troponin) were randomised 1:1 to an intervention-guided strategy plus OMT versus OMT alone. The primary endpoint was a composite of all-cause mortality and non-fatal myocardial reinfarction at 1 year. Ethics approval was obtained by the institutional review board of every recruiting centre.

Results: From May 2014 to September 2018, 251 patients (n=125 invasive vs n=126 conservative) were enrolled. Almost 50% of participants were female. The trial was terminated prematurely due to slow recruitment. A Kaplan-Meier estimate of event-free survival revealed no difference in the primary endpoint at 1 year (invasive 18.5% [23/124] vs conservative 22.2% [28/126]; p=0.39). No significant difference persisted after Cox proportional hazards regression analysis (hazard ratio 0.79, 95% confidence interval 0.45-1.35; p=0.39). There was greater freedom from angina at 3 months (p<0.001) after early intervention but this was similar at 1 year. Both non-fatal reinfarction (invasive 9.7% [12/124] vs conservative 14.3% [18/126]; p=0.22) and unplanned revascularisation (invasive 1.6% [2/124] vs conservative 6.4% [8/126]; p=0.10) occurred more frequently in the OMT alone cohort.

Conclusions: An intervention-guided strategy was not superior to OMT alone to treat very elderly NSTEMI patients. The trial was underpowered to demonstrate this definitively. Early intervention resulted in fewer cases of reinfarction and unplanned revascularisation but did not improve survival.

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acs/nste-acselderly (>75)nstemi
Coronary interventionsNSTEMI
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