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oai:recercat.cat:11351/113732025-10-24T10:34:00Zcom_2072_378070com_2072_378040col_2072_378092

Invasive Treatment Strategy in Adults With Frailty and Non–ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of a Randomized Clinical Trial Sanchis, Juan BUENO, HECTOR García-Blas, Sergio Alegre, Oriol Martí, David Martinez-Selles, Manuel García del Blanco, Bruno Angiografia Infart de miocardi - Tractament ANALYTICAL, DIAGNOSTIC AND THERAPEUTIC TECHNIQUES, AND EQUIPMENT::Therapeutics::Conservative Treatment ANALYTICAL, DIAGNOSTIC AND THERAPEUTIC TECHNIQUES, AND EQUIPMENT::Diagnosis::Diagnostic Techniques and Procedures::Diagnostic Imaging::Cardiac Imaging Techniques::Coronary Angiography DISEASES::Pathological Conditions, Signs and Symptoms::Pathologic Processes::Frailty DISEASES::Cardiovascular Diseases::Heart Diseases::Myocardial Ischemia::Myocardial Infarction::Non-ST Elevated Myocardial Infarction TÉCNICAS Y EQUIPOS ANALÍTICOS, DIAGNÓSTICOS Y TERAPÉUTICOS::terapéutica::tratamiento conservador TÉCNICAS Y EQUIPOS ANALÍTICOS, DIAGNÓSTICOS Y TERAPÉUTICOS::diagnóstico::técnicas y procedimientos diagnósticos::diagnóstico por imagen::técnicas de imagen cardíaca::angiografía coronaria ENFERMEDADES::afecciones patológicas, signos y síntomas::procesos patológicos::fragilidad ENFERMEDADES::enfermedades cardiovasculares::enfermedades cardíacas::isquemia miocárdica::infarto de miocardio::infarto de miocardio sin elevación del ST Invasive treatment; Myocardial infarction; ST-segment Tractament invasiu; Infart de miocardi; Segment ST Tratamiento invasivo; Infarto de miocardio; Segmento ST Importance The MOSCA-FRAIL randomized clinical trial compared invasive and conservative treatment strategies in patients with frailty with non–ST-segment elevation myocardial infarction (NSTEMI). It showed no differences in the number of days alive and out of the hospital at 1 year. Objective To assess the outcomes of the MOSCA-FRAIL trial during extended follow-up. Design, Setting, and Participants The MOSCA-FRAIL randomized clinical trial was conducted at 13 hospitals in Spain between July 7, 2017, and January 9, 2021, and included 167 adults (aged ≥70 years) with frailty (Clinical Frailty Scale score ≥4) and NSTEMI. In this preplanned secondary analysis, follow-up was extended to January 31, 2023. Data analysis was performed from April 5 to 29, 2023, using the intention-to-treat principle. Interventions Patients were randomized to a routine invasive (coronary angiography and revascularization if feasible [n = 84]) or a conservative (medical treatment with coronary angiography only if recurrent ischemia [n = 83]) strategy. Main outcomes and measures The primary end point was the difference in restricted mean survival time (RMST). Secondary end points included readmissions for any cause, considering recurrent readmissions. Results Among the 167 patients included in the analysis, the mean (SD) age was 86 (5) years; 79 (47.3%) were men and 88 (52.7%) were women. A total of 93 deaths and 367 readmissions accrued. The RMST for all-cause death over the entire follow-up was 3.13 (95% CI, 2.72-3.60) years in the invasive and 3.06 (95% CI, 2.84-3.32) years in the conservative treatment groups. The RMST analysis showed inconclusive differences in survival time (invasive minus conservative difference, 28 [95% CI, −188 to 230] days). Patients under invasive treatment tended to have shorter survival in the first year (−28 [95% CI, −63 to 7] days), which improved after the first year (192 [95% CI, 90-230] days). Kaplan-Meier mortality curves intersected, displaying higher mortality to 1 year in the invasive group that shifted to a late benefit (landmark analysis hazard ratio, 0.58 [95% CI, 0.33-0.99]; P = .045). Early harm was more evident in the subgroup with a Clinical Frailty Scale score greater than 4. No differences were found for the secondary end points. Conclusions and Relevance In this extended follow-up of a randomized clinical trial of patients with frailty and NSTEMI, an invasive treatment strategy did not improve outcomes at a median follow-up of 1113 (IQR, 443-1441) days. However, a differential distribution of deaths was observed, with early harm followed by later benefit. The phenomenon of depletion of susceptible patients may be responsible for this behavior. Trial registration ClinicalTrials.gov Identifier: NCT03208153 This study was supported by grants FIS 17/01736 and FIS 17/00899 from Spain’s Ministry of Science and Innovation through the Carlos III Health Institute: Fondo Europeo de Desarrollo Regional and by grant 16/11/00420 from Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares. 2025-10-24T10:34:00Z 2025-10-24T10:34:00Z 2025-10-24T10:34:00Z 2024-04-25T10:05:40Z 2024-04-25T10:05:40Z 2024-03-04 info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion http://hdl.handle.net/11351/11373 JAMA Network Open;7(3) https://doi.org/10.1001/jamanetworkopen.2024.0809 Attribution 4.0 International http://creativecommons.org/licenses/by/4.0/ info:eu-repo/semantics/openAccess American Medical Association Scientia