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The role of a routine invasive strategy in patients with non-ST segment elevation acute coronary syndromes remains a subject of debate. Following the results of several randomised trials many clinicians consider that an invasive strategy should be used in most patients but, in real-world practice, many centres tend to use a routine invasive strategy in younger patients, and a more selective approach in older individuals, in whom the presence of comorbidities is often perceived as a limitation to performing coronary angiography.1 The results of the pooled analysis of the Fragmin and Fast Revascularisation during Instability in Coronary Artery Disease (FRISC-II), Invasive Versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) and Randomized Trial of a Conservative Treatment Strategy Versus an Interventional Treatment Strategy in Patients with Unstable Angina (RITA-3) trials, presented in a paper published in Heart, therefore appear particularly challenging.2
In their study, Damman et al2 have analysed the impact of the initial management strategy (routine invasive or selective invasive) on the 5-year risk of cardiovascular death or myocardial infarction (MI), according to the patients' age categories. Although the main objective of the study was to confirm (or refute) the positive role of an invasive strategy in elderly patients (an age category often underrepresented in randomised trials), the most striking finding was that a routine strategy in younger patients (<65 years) was not associated with a reduction in the composite endpoint of cardiovascular death or MI, while such a strategy appeared beneficial in patients older than 65 years, including those over the age of 75 years. The unfavourable results of the invasive strategy in the younger patients were most probably drawn by the results of …