Bach Richard G, Cannon Christopher P, Weintraub William S, DiBattiste Peter M, Demopoulos Laura A, Anderson H Vernon, DeLucca Paul T, Mahoney Elizabeth M, Murphy Sabina A, Braunwald Eugene
Cardiovascular Division, Washington University Medical Center, St. Louis, Missouri 63110, USA.
Ann Intern Med. 2004 Aug 3;141(3):186-95. doi: 10.7326/0003-4819-141-3-200408030-00007.
Although increasing age is an important risk factor for adverse outcome among patients with acute coronary syndromes, elderly patients are more often managed conservatively.
To examine outcome according to age and management strategy for patients with unstable angina and non-ST-segment elevation myocardial infarction (MI).
Randomized, controlled trial conducted from December 1997 to June 2000.
169 community and tertiary care hospitals in 9 countries.
2220 patients hospitalized with unstable angina and non-ST-segment elevation MI who were randomly assigned to an early invasive or conservative management strategy.
Medical therapy and coronary angiography at 4 to 48 hours versus medical therapy and predischarge exercise testing.
Rates of 30-day and 6-month mortality, nonfatal MI, rehospitalization, stroke, and hemorrhagic complications.
Among patients 65 years of age and older, the early invasive strategy compared with the conservative strategy yielded an absolute reduction of 4.8 percentage points (8.8% vs. 13.6%; P = 0.018) and a relative reduction of 39% in death or MI at 6 months. Outcomes of the 2 strategies were similar, however, among patients younger than 65 years of age (6.1% vs. 6.5%; P > 0.2). Among patients older than 75 years of age, the early invasive strategy conferred an absolute reduction of 10.8 percentage points (10.8% vs. 21.6%; P = 0.016) and a relative reduction of 56% in death or MI at 6 months. The additional cost per death or MI prevented with the early invasive strategy was lower for elderly patients, but major bleeding rates were higher with this strategy in patients older than 75 years of age (16.6% vs. 6.5%; P = 0.009).
Because this study involved patients in the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction (TACTICS-TIMI) 18 trial, its generalizability to elderly patients with excluded comorbid conditions is unknown.
Despite an increased risk for major bleeding in patients older than 75 years of age, a routine early invasive strategy can significantly improve ischemic outcomes in elderly patients with unstable angina and non-ST-segment elevation MI.
尽管年龄增长是急性冠状动脉综合征患者不良预后的重要危险因素，但老年患者更常采用保守治疗。
根据年龄和治疗策略研究不稳定型心绞痛和非ST段抬高型心肌梗死（MI）患者的预后。
1997年12月至2000年6月进行的随机对照试验。
9个国家的169家社区和三级护理医院。
2220例因不稳定型心绞痛和非ST段抬高型MI住院的患者，随机分配至早期侵入性或保守治疗策略组。
4至48小时进行药物治疗和冠状动脉造影与药物治疗及出院前运动试验。
30天和6个月死亡率、非致死性MI、再住院率、中风和出血并发症发生率。
在65岁及以上患者中，与保守策略相比，早期侵入性策略使6个月时死亡或MI的绝对降低率为4.8个百分点（8.8%对13.6%；P = 0.018），相对降低率为39%。然而，在65岁以下患者中，两种策略的预后相似（6.1%对6.5%；P > 0.2）。在75岁以上患者中，早期侵入性策略使6个月时死亡或MI的绝对降低率为10.8个百分点（10.8%对21.6%；P = 0.016），相对降低率为56%。早期侵入性策略预防每例死亡或MI的额外成本在老年患者中较低，但该策略在75岁以上患者中的大出血发生率较高（16.6%对6.5%；P = 0.009）。
由于本研究纳入了心肌梗死溶栓治疗18（TACTICS-TIMI）试验中使用阿昔单抗治疗心绞痛并确定侵入性或保守策略治疗成本的患者，其对排除合并症的老年患者的普遍适用性尚不清楚。
尽管75岁以上患者大出血风险增加，但常规早期侵入性策略可显著改善不稳定型心绞痛和非ST段抬高型MI老年患者的缺血性预后。
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