@article{6ff053e092c043ea8c7065149d7d9b37,
title = "Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data",
abstract = "BACKGROUND: Previous trials suggest lower long-term risk of mortality after invasive rather than non-invasive management of patients with non-ST elevation myocardial infarction (NSTEMI), but the trials excluded very elderly patients. We aimed to estimate the effect of invasive versus non-invasive management within 3 days of peak troponin concentration on the survival of patients aged 80 years or older with NSTEMI.METHODS: Routine clinical data for this study were obtained from five collaborating hospitals hosting NIHR Biomedical Research Centres in the UK (all tertiary centres with emergency departments). Eligible patients were 80 years old or older when they underwent troponin measurements and were diagnosed with NSTEMI between 2010 (2008 for University College Hospital) and 2017. Propensity scores (patients' estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and compared the rate of hospital admissions for heart failure.FINDINGS: Of the 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1500 patients had a median age of 86 (IQR 82-89) years of whom (845 [56%] received non-invasive management. During median follow-up of 3·0 (IQR 1·2-4·8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the non-invasive management group (adjusted hazard ratio 0·68, 95% CI 0·55-0·84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48-0·93).INTERPRETATION: The survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older.FUNDING: NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative.",
keywords = "Age Factors, Aged, 80 and over, Cohort Studies, Female, Hospitalization, Humans, Logistic Models, Male, Non-ST Elevated Myocardial Infarction/diagnosis, Propensity Score, Survival Rate, Troponin/blood, United Kingdom",
author = "Amit Kaura and Sterne, {Jonathan A C} and Adam Trickey and Sam Abbott and Abdulrahim Mulla and Benjamin Glampson and Vasileios Panoulas and Jim Davies and Kerrie Woods and Joe Omigie and Shah, {Anoop D} and Channon, {Keith M} and Weber, {Jonathan N} and Thursz, {Mark R} and Paul Elliott and Harry Hemingway and Bryan Williams and Asselbergs, {Folkert W} and Michael O'Sullivan and Lord, {Graham M} and Narbeh Melikian and Thomas Johnson and Francis, {Darrel P} and Shah, {Ajay M} and Divaka Perera and Rajesh Kharbanda and Patel, {Riyaz S} and Jamil Mayet",
note = "Funding Information: This research has been done using National Institute for Health Research Health Informatics Collaborative (NIHR HIC) data resources. The NIHR HIC is a joint initiative between the NIHR Biomedical Research Centres at Imperial College London (London), Oxford, Bristol, University College London Hospitals (London), Guy's and St Thomas' (London), and Cambridge, which has provided data services, infrastructure, and expertise. The Article follows the STROBE guidelines for the reporting of observational studies. This Article reports independent research led and funded by the NIHR Imperial Biomedical Research Centre (BRC), as part of the NIHR Health Informatics Collaborative with the NIHR Oxford BRC, the NIHR Bristol BRC, the NIHR University College London Hospitals BRC, the NIHR Guy's and St Thomas' BRC, and the NIHR Cambridge BRC. AK is funded by a British Heart Foundation clinical research training fellowship (FS/20/18/34972). JM is supported by the BHF Imperial Centre for Research Excellence (RE/18/4/34215). RSP is funded by a British Heart Foundation intermediate fellowship (FS/14/76/30933). ADS is funded by a THIS Institute postdoctoral fellowship. AMS is funded by a British Heart Foundation Professorship (CH/1999001/11735). JACS is funded by a NIHR Senior Investigator award (NF-SI-0611-10168). HH is funded by the NIHR University College London Hospitals Biomedical Research Centre, supported by Health Data Research UK (grant No. LOND1). PE and HH received Health Data Research funding. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health. Funding Information: This research has been done using National Institute for Health Research Health Informatics Collaborative (NIHR HIC) data resources. The NIHR HIC is a joint initiative between the NIHR Biomedical Research Centres at Imperial College London (London), Oxford, Bristol, University College London Hospitals (London), Guy's and St Thomas' (London), and Cambridge, which has provided data services, infrastructure, and expertise. The Article follows the STROBE guidelines for the reporting of observational studies. This Article reports independent research led and funded by the NIHR Imperial Biomedical Research Centre (BRC), as part of the NIHR Health Informatics Collaborative with the NIHR Oxford BRC, the NIHR Bristol BRC, the NIHR University College London Hospitals BRC, the NIHR Guy's and St Thomas' BRC, and the NIHR Cambridge BRC. AK is funded by a British Heart Foundation clinical research training fellowship (FS/20/18/34972). JM is supported by the BHF Imperial Centre for Research Excellence (RE/18/4/34215). RSP is funded by a British Heart Foundation intermediate fellowship (FS/14/76/30933). ADS is funded by a THIS Institute postdoctoral fellowship. AMS is funded by a British Heart Foundation Professorship (CH/1999001/11735). JACS is funded by a NIHR Senior Investigator award (NF-SI-0611-10168). HH is funded by the NIHR University College London Hospitals Biomedical Research Centre, supported by Health Data Research UK (grant No. LOND1). PE and HH received Health Data Research funding. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health. Publisher Copyright: {\textcopyright} 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Copyright: Copyright 2021 Elsevier B.V., All rights reserved.",
year = "2020",
month = aug,
day = "29",
doi = "10.1016/S0140-6736(20)30930-2",
language = "English",
volume = "396",
pages = "623--634",
journal = "The Lancet",
issn = "0140-6736",
publisher = "Elsevier",
number = "10251",
}