Invasive Strategy Offers No Benefit in Frail Older Adults With NSTEMI

Frail older adults hospitalized with non–ST-elevation myocardial infarction (NSTEMI) did not experience improved outcomes with a routine invasive strategy compared with conservative medical management, according to new research.

This prespecified exploratory subgroup analysis is published in JAMA Network Open.¹

“Our findings suggest that, among frail patients, an invasive approach was not associated with a statistically significant reduction in the primary composite outcome or its individual components,” wrote the researchers of the study. “Conversely, there was a numerical increase in adverse events, particularly cardiovascular death, in the invasive group, although this did not reach statistical significance.”

The analysis drew on data from the SENIOR-RITA randomized clinical trial, which enrolled patients aged 75 years or older with NSTEMI across 48 National Health Service trusts in England and Scotland between November 2016 and March 2023. Participants were randomized to either an invasive strategy—consisting of coronary angiography with revascularization as appropriate plus optimal medical therapy—or a conservative strategy of optimal medical therapy alone. Frailty status was assessed using the Fried frailty criteria, with patients classified as frail if they met 3 or more criteria.

The primary end point was time to cardiovascular death or nonfatal myocardial infarction (MI), and outcomes were analyzed according to the intention-to-treat principle over a median (IQR) follow-up of 4.1 (2.8-4.6) years.

Among the 1446 patients with available frailty data, 469 (32.4%) were classified as frail, with a median age of 83 years and just over half women (51.2%). In this subgroup, the primary composite outcome of cardiovascular death or nonfatal MI occurred in 37.7% of patients assigned to an invasive strategy (87 of 231) compared with 29.4% of those receiving conservative management (70 of 238), yielding a hazard ratio (HR) of 1.21 (95% CI, 0.88-1.67). No significant differences were observed between treatment groups for cardiovascular death alone (HR, 1.44; 95% CI, 0.97-2.10) or nonfatal MI (HR, 1.00; 95% CI, 0.61-1.63).

Notably, when frailty was analyzed as a continuous variable, a significant interaction emerged, suggesting that patients with the highest levels of frailty may face an increased risk of adverse outcomes with a routine invasive approach.

However, several limitations should be considered when interpreting these findings. The relatively small size of the frail subgroup and lack of adjustment for multiple comparisons limit statistical power and render the results hypothesis-generating, while the absence of detailed data on causes of cardiovascular death restricts mechanistic insights. Additionally, potential selection bias—given that more severely frail patients were less likely to be randomized—and the use of the Fried frailty criteria, rather than other measures, may affect generalizability and treatment effect estimates.

Despite these limitations, the researchers believe these findings reinforce the need for individualized, frailty-informed decision-making when considering invasive management strategies in older adults with NSTEMI.

Consistent with prior evidence and guideline uncertainty around managing older adults with NSTEMI, a recent systematic review and meta-analysis of randomized trials in patients aged 75 years and older found no significant reduction in death or MI with routine invasive strategies compared with conservative management.² These findings reinforce the SENIOR-RITA results and further highlight the lack of clear benefit of invasive approaches in frail or very elderly populations, supporting individualized, risk-based treatment decisions.

“Although the study may be underpowered, the results indicate that invasive management may not provide clinical benefit for older populations at the highest levels of frailty and underscore the need for individualized, frailty-informed treatment strategies,” wrote the researchers.¹

References

1. Rubino F, Mossop H, Ripley DP, et al. Invasive vs conservative strategy for frail older patients with myocardial infarction. JAM Netw Open. 2026;9(4):e267316. doi:10.1001/jamanetworkopen.2026.7316

2. Rout A, Moumneh MB, Kalra K, et al. Invasive versus conservative strategy in older adults ≥75 years of age with non-ST-segment-elevation acute coronary syndrome: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2024;13(21):e036151. doi:10.1161/JAHA.124.036151