Routine invasive management might not improve cardiovascular outcomes in frail older adults with non-ST-elevation myocardial infarction (NSTEMI), according to a recent analysis that underscores the importance of personalised frailty-informed treatment.

Published in the journal JAMA Network Open, the study aimed to clarify whether invasive management provides clinical benefit in frail older patients with NSTEMI – a population historically under-represented in randomised cardiovascular trials despite experiencing high rates of adverse outcomes.

A prespecified subgroup analysis of the SENIOR-RITA randomised clinical trial, conducted across 48 NHS Trusts in England and Scotland, was undertaken.

Patients aged 75 years or older with NSTEMI were randomised to either coronary angiography, revascularisation where appropriate, and optimal medical therapy, or a conservative strategy of optimal medical therapy alone.

Frailty status, assessed using the Fried frailty criteria, was available for 1,446 of 1,518 randomised participants, of whom 469 met the criteria for frailty.

Median age within the frail cohort was 83 years, 51.2% were women, and participants demonstrated higher comorbidity burden, cognitive impairment and Global Registry of Acute Coronary Events risk scores compared with pre-frail and robust patients.

The primary endpoint was a composite of cardiovascular death or non-fatal myocardial infarction (MI). Secondary outcomes included all-cause mortality, recurrent MI, stroke, transient ischaemic attack, bleeding, heart failure hospitalisation and subsequent coronary intervention.

Influence of frailty severity on NSTEMI treatment

Over a median follow-up of 4.1 years, the primary outcome occurred in 37.7% of frail patients assigned to invasive NSTEMI management compared with 29.4% of those managed conservatively (hazard ratio [HR] 1.21; 95% CI 0.88–1.67; P=0.20).

Cardiovascular death occurred in 25.5% and 18.5% of patients, respectively (HR 1.44; 95% CI 0.97–2.10), while rates of non-fatal MI were similar between groups.

When analysed as a continuous variable, a statistically significant interaction between frailty severity and treatment effect emerged, suggesting that patients at the highest frailty levels may experience worse outcomes with routine invasive management.

Secondary outcomes between invasive and conservative strategies among frail patients with NSTEMI did not differ significantly. However, patients assigned to invasive management underwent fewer subsequent coronary angiography and revascularisation procedures during follow-up.

Reasons for not proceeding with angiography included clinical decision-making, patient preference and individuals becoming too unwell.

Procedural complications were more common among frail patients, although rates remained low overall, and most individual complications occurred in fewer than 1% of patients.

Frailty-informed decision-making

It was noted that the findings align with those of the MOSCA-FRAIL trial, which also failed to demonstrate a clear clinical benefit of routine invasive treatment in frail older adults with NSTEMI.

The authors suggested that this increased vulnerability, competing comorbidities and limited physiological reserve may attenuate the expected benefits of revascularisation in highly frail patients.

Several study limitations were acknowledged, including the exploratory subgroup design, limited statistical power in the frail subgroup, delays in angiography and the potential for residual confounding.

Nevertheless, the authors concluded that the findings reinforce the importance of systematic frailty assessment and shared decision-making when considering invasive management for older adults with NSTEMI, and that further frailty-specific trials are needed to better define optimal treatment.

Reference
Rubino F et al. Invasive vs conservative strategy for frail older patients with myocardial infarction: a secondary analysis of the SENIOR-RITA randomized clinical trial. JAMA Network Open 2026;9(4):e267316.