Geriatric conditions and invasive management in frail patients with NSTEMI. A subgroup analysis of a randomized clinical trial

Invasive management in frail patients with non–ST-segment elevation myocardial infarction (NSTEMI) remains controversial. We investigated the impact of various geriatric conditions. The MOSCA-FRAIL trial included 167 adults aged ≥ 70 years with frailty (Clinical Frailty Scale [CFS] ≥ 4 points) and NSTEMI, who were randomized to either an invasive (n=84) or conservative (n=83) strategy. In addition to frailty, we measured activities of daily living (Barthel index), cognitive impairment (Pfeiffer test), and comorbidities (Charlson index). The primary endpoint was the difference (invasive minus conservative) in restricted mean survival time (RMST) for all-cause mortality at a median follow-up of 3.9 years. A total of 93 patients died. The RMST difference favored invasive management at the CFS 25th percentile (CFS=4; 157 days, 95%CI, 18-295; P=.027), which changed to a nonsignificant effect at the 50th and 75th percentiles. The RMST difference remained nonsignificant, irrespective of the severity of other geriatric assessments. In time-to-event analysis, invasive management was associated with an initially lower life expectancy, peaking at around 1 year, among all subgroups. However, patients with CFS=4 experienced a benefit at the end of follow-up (181 days, 95%CI, 19-343), whereas those with CFS >4 did not (−16 days, 95%CI, −217 to 186; interaction P=.16). Subgroups defined by other geriatric markers showed a similar time-dependent trend, albeit with weaker statistical interaction. Among adults with frailty and NSTEMI, the CFS might be useful for evaluating the relative risks and benefits of invasive management. A CFS >4 could serve as a valuable threshold for decision-making. El tratamiento invasivo de los pacientes frágiles con infarto agudo de miocardio sin elevación del segmento ST (IAMSEST) es motivo de controversia. El objetivo es investigar el impacto de las condiciones geriátricas. El ensayo MOSCA-FRAIL incluyó a 167 adultos de edad ≥ 70 años con fragilidad (escala de fragilidad clínica [CFS] ≥ 4 puntos) e IAMSEST aleatorizados a estrategia invasiva (n=84) o conservadora (n=83). Además de la fragilidad, se midieron las actividades de la vida diaria (índice de Barthel), el deterioro cognitivo (test de Pfeiffer) y las comorbilidades (índice de Charlson). El objetivo primario fue la diferencia (invasiva menos conservadora) en el tiempo medio de supervivencia restringido (TMSR) para la mortalidad por todas las causas, en una mediana de seguimiento de 3,9