SENOR-RITA Trial Results Call for Nuanced Shared Decision-Making for Elderly Patients With NSTEMI

The SENIOR-RITA trial, presented at ESC 2024 and published in The New England Journal of Medicine, investigates the optimal management strategy for older adults with non-ST-segment elevation myocardial infarction (NSTEMI). Current guidelines from the ACC/AHA and ESC recommend an invasive approach for NSTEMI regardless of age. Still, the evidence supporting invasive treatment in patients over 75 years old is less clear. Older patients often have a higher burden of frailty, cognitive impairment, and comorbidities, making them less likely to receive guideline-directed invasive strategies.

SENIOR-RITA, a prospective, multicenter randomized trial, enrolled 1,518 patients aged 75 or older with NSTEMI across 48 sites in the UK (mean age of 82 years, 45% women, 32% frail according to the Fried Frailty Index, 62.5% with cognitive impairment). Patients were randomly assigned to either an invasive strategy (coronary angiography followed by revascularization if appropriate, N = 753) or a conservative approach (medical therapy alone, N = 765). The primary composite outcome was cardiovascular death or nonfatal myocardial infarction (MI) over a median follow-up of 4.1 years. Notably, the trial may have been underpowered given a smaller than targeted sample size (1,518 patients rather than the goal of 1,668) with a lower incidence of the primary outcome than anticipated.

The trial found no significant difference in the primary outcome between the two groups, with 25.6% of patients in the invasive group and 26.3% in the conservative group experiencing cardiovascular death or nonfatal MI (HR, 0.94; 95% CI, 0.77 to 1.14; p=0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred at similar rates in both groups, but the invasive group had a modest reduction in nonfatal MI (11.7% vs. 15.0%, HR, 0.75; 95% CI, 0.57 to 0.99). The conservatively managed group had higher rates of subsequent coronary angiography and coronary revascularization, but these comparisons are difficult to interpret and may have been driven by clinician and/or patient preference with knowledge of randomization rather than clinical need. Importantly, procedural complications in the invasive group were low, occurring in less than 1% of patients, likely due to the predominant use of radial access. Interestingly, the median time from hospital admission to coronary angiography in the invasive arm was five days, which seems to be delayed compared to typical practice. Nearly 50% of these patients underwent a revascularization procedure.

The results from SENIOR-RITA are consistent with prior data, including a recent meta-analysis by Kotanidis et al., which pooled individual patient data from six randomized trials involving older patients with NSTEMI. This meta-analysis showed that while routine invasive treatment did not reduce all-cause mortality or the composite endpoint of mortality and MI within one year, it significantly lowered the risk of recurrent MI and urgent revascularization (HR for MI, 0.62; 95% CI, 0.44 to 0.87)​. These findings suggest that an invasive strategy offers some benefits in reducing future ischemic events but may not confer a mortality advantage in this population.

The clinical relevance of the SENIOR-RITA trial lies in its contribution to shared decision-making for older NSTEMI patients. While invasive treatment reduces nonfatal MI, it does not lower overall mortality, and the risks of intervention must be carefully weighed against the patient’s frailty, comorbidities, and life expectancy. For many older patients, a conservative approach may be equally appropriate, particularly for those with high procedural risk and comorbidity burden with non-cardiovascular competing risk of mortality. The results of SENIOR-RITA, combined with previous evidence, offer clinicians valuable data to individualize care and guide heart team discussions in this vulnerable population. It frees clinicians from feeling obligated to send every elderly patient to the cath lab, favoring the art of medicine and prioritizing patient values and shared decision-making.

References

1. Kunadian V, Mossop H, Shields C, et al. Invasive Treatment Strategy for Older Patients with Myocardial Infarction. N Engl J Med. 2024; DOI:10.1056/NEJMoa2407791.
2. Kotanidis CP, Mills GB, Bendz B, et al. Invasive vs. Conservative Management of Older Patients with Non-ST-Elevation Acute Coronary Syndrome: Individual Patient Data Meta-analysis. Eur Heart J. 2024;45(23):2052-2062. DOI:10.1093/eurheartj/ehae151.
3. Lawton JS, Tamis-Holland JE, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(3). DOI: https://doi.org/10.1161/CIR.0000000000001038.
4. Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the Management of Acute Coronary Syndromes. Eur Heart J. 2023;44(38):3720-3826. DOI: https://doi.org/10.1093/eurheartj/ehad191.