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Effects of age on long-term outcomes after a routine invasive or selective invasive strategy in patients presenting with non-ST segment elevation acute coronary syndromes: a collaborative analysis of individual data from the FRISC II - ICTUS - RITA-3 (FIR) trials
  1. Peter Damman1,
  2. Tim Clayton2,
  3. Lars Wallentin3,
  4. Bo Lagerqvist3,
  5. Keith A A Fox4,
  6. Alexander Hirsch1,
  7. Fons Windhausen1,
  8. Eva Swahn5,
  9. Stuart J Pocock2,
  10. Jan G P Tijssen1,
  11. Robbert J de Winter1
  1. 1Department of Cardiology, Academic Medical Center—University of Amsterdam, Amsterdam, The Netherlands
  2. 2London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
  3. 3Department of Cardiology, Cardiothoracic Center, University Hospital, Uppsala, Sweden
  4. 4Cardiovascular Research, Department of Medical and Radiological Sciences, Royal Infirmary, Edinburgh, UK
  5. 5Department of Cardiology, Heart Centre, University Hospital, Linköping, Sweden
  1. Correspondence to Robbert J de Winter, Department of Cardiology, Cardiac Catheterisation Laboratory B2-137, Academic Medical Center—University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; r.j.dewinter{at}


Objective To perform a patient-pooled analysis of a routine invasive versus a selective invasive strategy in elderly patients with non-ST segment elevation acute coronary syndrome.

Methods A meta-analysis was performed of patient-pooled data from the FRISC II–ICTUS–RITA-3 (FIR) studies. (Un)adjusted HRs were calculated by Cox regression, with adjustments for variables associated with age and outcomes. The main outcome was 5-year cardiovascular death or myocardial infarction (MI) following routine invasive versus selective invasive management.

Results Regarding the 5-year composite of cardiovascular death or MI, the routine invasive strategy was associated with a lower hazard in patients aged 65–74 years (HR 0.72, 95% CI 0.58 to 0.90) and those aged ≥75 years (HR 0.71, 95% CI 0.55 to 0.91), but not in those aged <65 years (HR 1.11, 95% CI 0.90 to 1.38), p=0.001 for interaction between treatment strategy and age. The interaction was driven by an excess of early MIs in patients <65 years of age; there was no heterogeneity between age groups concerning cardiovascular death. The benefits were smaller for women than for men (p=0.009 for interaction). After adjustment for other clinical risk factors the HRs remained similar.

Conclusion The current analysis of the FIR dataset shows that the long-term benefit of the routine invasive strategy over the selective invasive strategy is attenuated in younger patients aged <65 years and in women by the increased risk of early events which seem to have no consequences for long-term cardiovascular mortality. No other clinical risk factors were able to identify patients with differential responses to a routine invasive strategy.

  • Non-ST-elevation acute coronary syndrome
  • treatment strategy
  • elderly
  • gender
  • stemi
  • risk factors
  • acute coronary syndrome
  • reperfusion
  • nstemi
  • angina
  • unstable
  • cardiac remodelling
  • risk stratification
  • MRI
  • acute ischaemic syndromes

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  • See Editorial, p 173

  • Competing interests The collaboration and meta-analysis were conducted using resources from the host institutions for the respective studies (KAAF is supported by the British Heart Foundation; LW is supported by the Swedish Heart Foundation) and from the London School of Hygiene and Tropical Medicine. KAAF has received grants and honoraria from Sanofi-Aventis/Bristol-Myers Squibb, GlaxoSmithKline, Lilly and AstraZeneca. SJP has consulted for The Medicines Company and has served on a Boston Scientific-sponsored Data Monitoring Committee.

  • Ethics approval British, Dutch and Swedish local ethics committees approved the original studies.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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