Updated evidence on selection and implementation of an invasive treatment strategy for older patients with non-ST-segment elevation myocardial infarction

Non-ST-segment elevation myocardial infarction (NSTEMI) is the most common acute coronary syndrome diagnosis in older patients. In the UK, there are ~20 000 NSTEMI cases annually in patients aged ≥75 years. Despite therapeutic advances in pharmacological and invasive management, studies show that older patients with NSTEMI experience worse in-hospital and long-term outcomes than younger patients, suggesting a clear need for robust evidence in this cohort. The European Society of Cardiology guidelines recommend that invasive management should be considered holistically with no specified age cut-offs. However, older patients are less likely to receive invasive management due to a paucity of evidence from trials that represent contemporary clinical characteristics of older adults. Recruiting older patients realistic of those encountered in clinical practice is hugely challenging. Chronological age alone does not reflect the heterogeneity of the older population; ~30% of older patients with NSTEMI are frail, ~65% are cognitively impaired and most live with at least two additional comorbidities that can influence risk. Weighing the risk of an NSTEMI in an older adult against competing risks attributable to underlying frailty, comorbidities and cognitive impairment poses a key challenge. Recently, the SENIOR-RITA trial showed that invasive management in older patients with NSTEMI is safe and reduces non-fatal myocardial infarction and subsequent revascularisation but does not improve mortality. Individualised risk assessment and shared decision-making is necessary to guide these nuanced decisions. This review discusses the latest evidence regarding invasive management in the older population with NSTEMI, including the impact of geriatric syndromes on clinical outcomes.