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Invasive vs. Medical Therapy for Elderly CAD Patients

Investigators report one-year results from the TIME trial.

Coronary revascularization benefits patients with chronic, symptomatic coronary artery disease who are younger than 75, but data for older patients have been sparse. In the TIME trial from Switzerland, 301 patients (minimum age, 75) with chronic stable angina despite treatment with at least 2 antianginal drugs were randomized to optimal medical therapy or to invasive therapy. By 6 months, the invasive strategy had improved symptoms and quality of life (QOL), but at a cost of slightly higher short-term mortality than with the medical strategy (Journal Watch Cardiology Nov 30 2001). Now, the investigators report 1-year results.

For both groups of 6-month survivors (140 in the invasive group, 142 in the medical group), mean age was 80 and 42% were women. The primary 1-year endpoints were questionnaire-assessed QOL and incidence of major adverse clinical events (MACE; death, nonfatal MI, or hospitalization for acute coronary syndrome).

By 1 year, improvements in angina symptoms and QOL were similar in the 2 groups. Significantly fewer rehospitalizations that included revascularization had occurred in the invasive group than in the medical group by 1 year (roughly 10% vs. 46%). However, 1-year between-groups differences were not significant for mortality incidence (11% and 8%, respectively) nor for the composite of death or nonfatal MI (17% vs. 20%). One-year MACE incidence was significantly lower in the invasive group (25.5%) than in the medical group (64.2%).

Comment: One-year improvements in anginal symptoms and QOL in the elderly were roughly equivalent with an early-revascularization strategy and a strategy of early medical therapy with late revascularization. The invasive strategy was associated with greater early mortality, the medical strategy with greater long-term incidence of MACE. Therefore, as the editorialist notes, clinicians and their elderly patients must weigh the up-front risks and early QOL benefits of the invasive strategy against the longer-term MACE and urgent-intervention risks of the medical strategy. Further large-scale clinical trials are needed to tease out potential long-term mortality differences between the strategies.

— JoAnne M. Foody, MD

Published in Journal Watch Cardiology April 25, 2003

Citation(s):

Pfisterer M et al. for the Trial of Invasive versus Medical therapy in Elderly patients (TIME) Investigators. Outcome of elderly patients with chronic symptomatic coronary artery disease with an invasive vs optimized medical treatment strategy: One-year results of the randomized TIME trial. JAMA 2003 Mar 5; 289:1117-23.

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• Medline abstract (Free)

Peterson ED. Patient-centered cardiac care for the elderly: TIME for reflection. JAMA 2003 Mar 5; 289:1157-8.

• Original article (Subscription may be required)
• Medline abstract (Free)