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1/11
The Lancet just published the SENIOR-NSTEMI trial ( https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30930-2/fulltext) with very interesting findings:
The Lancet just published the SENIOR-NSTEMI trial ( https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30930-2/fulltext) with very interesting findings:
2/11
Prospective observational data from 5 collaborating Hospitals in the UK 2010-2017
NSTEMI patients
80 years or older
comparing invasive versus noninvasive management within 3 days of the peak troponin concentration
Prospective observational data from 5 collaborating Hospitals in the UK 2010-2017NSTEMI patients80 years or older comparing invasive versus noninvasive management within 3 days of the peak troponin concentration
3/11
excluding from the initial modelling steps patients who DIED within 3 days of peak troponin dosage (to avoid immortal time bias) and after propensity score adjustment (looking over more than 70 variables) and excluding pts extremes of propensity score strata
excluding from the initial modelling steps patients who DIED within 3 days of peak troponin dosage (to avoid immortal time bias) and after propensity score adjustment (looking over more than 70 variables) and excluding pts extremes of propensity score strata
4/11
the KM curve for all-cause mortality (weighted to inverse probability of treatment received) looks like this:
the KM curve for all-cause mortality (weighted to inverse probability of treatment received) looks like this:
5/11 we must congratulate the authors ( @ProfDFrancis between them) as it ADDS important information
1) Favours invasive strategy as routine in advanced age (usually excluded /underrepresented in RCTs)
2) Same findings as small randomised trials (AFTER-EIGHTY and Elderly-ACS)
1) Favours invasive strategy as routine in advanced age (usually excluded /underrepresented in RCTs)
2) Same findings as small randomised trials (AFTER-EIGHTY and Elderly-ACS)
6/11
3) Low bleeding rates of invasive strategy (reflecting higher radial use / low GIIb/IIIa use) even is this high risk pop.
3) Low bleeding rates of invasive strategy (reflecting higher radial use / low GIIb/IIIa use) even is this high risk pop.
7/11 ONE point caught my attention: Why the KM “opens” only after 1 year ??
Looking at meta-analysis of routine invasive x selected invasive trials in NSTEMI/UA the curves separates at 1 year but afterwards they look quite stable
https://pubmed.ncbi.nlm.nih.gov/20359842/ )
Looking at meta-analysis of routine invasive x selected invasive trials in NSTEMI/UA the curves separates at 1 year but afterwards they look quite stable
https://pubmed.ncbi.nlm.nih.gov/20359842/ )
8/11 Look at this KM (from : https://pubmed.ncbi.nlm.nih.gov/20359842/ )
9/11 HYPOTHESIS ?
1) Residual confounding ? (those with noninvasive management with known prior coronary anatomy and less amenable to revascularization ? other prognostic factors
1) Residual confounding ? (those with noninvasive management with known prior coronary anatomy and less amenable to revascularization ? other prognostic factors
10/11
2) Less ACS after 1 year in the invasive group due to more complete revascularization? Adjusted HR of 0.67 (95% CI 0.45-1.00 and P value 0.048) for less ACS in the follow up -favouring the invasive group (table S7, below) - prob NOT
2) Less ACS after 1 year in the invasive group due to more complete revascularization? Adjusted HR of 0.67 (95% CI 0.45-1.00 and P value 0.048) for less ACS in the follow up -favouring the invasive group (table S7, below) - prob NOT
