CATEGORY: HEART & CIRCULATION
Adults aged 75 and older treated for the most common kind of heart attack with medicines alone fared about the same as those who also received invasive artery-opening care—26.3% versus 25.6% went on to die of a cardiovascular cause or suffer another heart attack over roughly four years, a difference small enough to be chance—in a British randomized trial of 1,518 patients published in the New England Journal of Medicine.1 The trial, called SENIOR-RITA, matters because it enrolled exactly the patients earlier heart-attack trials tended to leave out: the very old, many of them frail or living with memory problems, for whom the value of an invasive approach had never been settled.
A Heart-Attack Trial That Finally Enrolled the Over-75s
The study focused on non-ST-elevation myocardial infarction, the commoner form of heart attack in which a coronary artery is severely narrowed or briefly blocked rather than suddenly and completely sealed off. Across 48 hospitals in England and Scotland, researchers recruited 1,518 such patients aged 75 or older—average age 82, the oldest 103, nearly half women, four in five of them prefrail or frail. Each was assigned by chance to one of two strategies. Both groups received the full set of recommended heart medicines. One group additionally underwent coronary angiography—a thin tube threaded from the wrist or groin up to the heart, where dye and X-rays map the blockages, much as a plumber feeds an inspection camera through pipes to find the clog—followed, where the pictures warranted it, by treatment to restore blood flow with a stent (a small mesh tube that props the artery open) or bypass surgery. Because chance decided who got the procedures, any difference in outcomes over the median 4.1 years of follow-up could be credited to the strategy itself.
Ninety Percent Got the Camera, Half Got a Repair
In the invasive group, 90% actually underwent angiography and about half went on to a procedure restoring blood flow. Yet on the trial’s main measure—cardiovascular death or a new nonfatal heart attack—the two strategies finished in a statistical tie: 25.6% with invasive care versus 26.3% with medicines alone, a hazard ratio of 0.94 with a confidence interval of 0.77 to 1.14. Cardiovascular death on its own was also no different, at 15.8% versus 14.2%. The procedures themselves proved remarkably safe in this age group: complications occurred in fewer than 1% of patients, and bleeding was no more common with the invasive approach.
What Opening the Arteries Did—and Did Not—Change
The investigators had set out to test whether routinely mapping and reopening arteries would cut deaths and new heart attacks; the combined measure did not move, and the lead investigator noted plainly that the invasive strategy did not reduce the trial’s primary endpoint, while adding that it appeared safe and carried some benefits. Those benefits were real but narrower than hoped. Later nonfatal heart attacks struck 11.7% of the invasive group against 15.0% of the medicines-alone group—about three fewer per hundred patients—and the need for a later, unplanned artery-opening procedure fell from 13.7% to 3.9%. What the procedures did not do, in patients this age, was help more of them survive.
Across Eight Trials, the Same Split Decision
A pooled analysis of eight randomized trials covering 3,887 older patients with this kind of heart attack, published in Frontiers in Cardiovascular Medicine, reached the same split verdict: no difference in deaths from any cause (risk ratio 1.05, confidence interval 0.93 to 1.17), but fewer repeat heart attacks (risk ratio 0.70) and far fewer later procedures with the invasive approach—alongside somewhat more severe bleeding across the pooled trials (risk ratio 1.43).2 For older patients and their families weighing options after this kind of heart attack, the evidence now describes a genuine trade: invasive care does not extend life at this age, but it lowers the chance of another heart attack and of needing an urgent procedure later, at the cost of a somewhat higher bleeding risk seen across the wider evidence.
Key Takeaways
- In adults 75 and older with the commoner type of heart attack, adding invasive artery-opening care to medicines did not lower the combined rate of cardiovascular death or repeat heart attack—25.6% versus 26.3% over about four years.
- Invasive care did reduce later nonfatal heart attacks (11.7% versus 15.0%) and later unplanned procedures (3.9% versus 13.7%), and procedural complications were rare even at advanced ages.
- Eight randomized trials pooled together show the same pattern—no survival difference, fewer repeat heart attacks, and somewhat more severe bleeding with the invasive approach.
References
- Kunadian V, Mossop H, Shields C, et al. Invasive Treatment Strategy for Older Patients with Myocardial Infarction. New England Journal of Medicine. 2024;391(18):1673–1684. link
- Vats V, Shahjehan RD, Kumar BS, et al. Invasive treatment strategy for older patients with non-ST-elevation acute coronary syndrome: a systematic review and meta-analysis of randomized controlled trials. Frontiers in Cardiovascular Medicine. 2025;12:1638932. link