12 Comments

The myocarditis fiasco of COVID-19 vaccine policy has thought many EBM enthusiasts that age stratification for study results cannot be ignored.

Expand full comment
founding

This points out the problem with any one-size-fits-all approach for anything. I would also question how well a study presumably of Spaniards would translate to non-Spaniards, and what role gender plays in this issue. Are most elderly frail patients women? And how about diabetes and obesity? I can ask a LOT of questions.

Expand full comment

You are correct. Studies are good, but they do not always apply to the patient in front of you. Every patient is different, no one is "normal" so standard protocol may not work for that patient. Effective communication with the patient and their caregiver is required. Listening, which does require humility.

Expand full comment

Thanks for highlighting this study. I read it with interest when it came out a few weeks ago, and shared amongst my hospital group right way. Indeed, the DAOH endpoint is a novel and seemingly highly relevant one for this age group.

As you suggest, we generally accept that an early invasive strategy is generally of benefit. The difficulty is reconciling that general principle with cases involving advancing age and increasing comorbidities.

The recent long term follow up of the After 80 study suggested that early invasive strategy was still generally of benefit in octogenarians (although even that study suggested any benefit was nullified after age 90, in general). And so as always, it boils down to tools for guiding appropriate pt selection.

In that regard, this study’s use of the Clinical Frailty Scale is provocative but also potentially problematic. I had never heard of it before and had to look it up. And it is most certainly a “scale” and not a “score”, as it is completely narrative based and subjective in nature. The study used a cut-off of 4 on the scale, which descriptively is “slowed up”, “tired during the day”, and “baseline symptoms limiting activities”. It seems to me that one clinician’s 3 could easily be another’s 4, or vice versa. It also seems to be that a lot of more elderly pts could easily be considered a 4…and it doesn’t quite augur with my gestalt that many/most of these pts would NOT benefit from an early invasive strategy. Still, this is trial data and not gut, and I can’t deny what was found in this study population, using the way CFS was applied upon them.

So moving forward, I intend to augment my general clinical guiding principle of “just because we can, doesn’t mean we should” with awareness of this scale, for situations where I am trying to decide upon treatment strategies for “edge” cases. And I am hoping studies like this will spur further work in this field in the future.

Expand full comment

One MAJOR problem with this study is use of the antiquated term "NSTEMI" for division of study patients. There is increasing evidence that at least 30% (if not more) of acute Occlusion MIs ( = OMIs) do not manifest ST elevation. As a result, a significant number of patients are diagnosed with a "NSTEMI" by default — when in reality, they really had acute occlusion of a major coronary artery ( = an "OMI"). This is highly problematic — because prognosis differs significantly depending on whether there is or is not acute coronary occlusion. And the diagnosis of an OMI can (and should) be made by optimal ECG interpretation of serial tracings, correlated to the presence and severity of symptoms AT THE TIME that each ECG is done (See — https://hqmeded-ecg.blogspot.com/2020/07/omi-nomi-paradigm-established-as-better.html ). So YES — I completely agree with the Sensible Medicine premise that "Using Evidence Requires Caution" — and that "caution" begins with appropriate selection of study groups (which was not done in this study).

Expand full comment

Regarding the novel primary endpoint - the number of days alive and out of the hospital after discharge - did everyone in the trial leave the hospital alive? Or are the results skewed because the patients who died after their MI treated w/conservative approach artificially increased number of days alive *after discharge*

Expand full comment

“First do no harm”.

Also want to emphasize that this was about the effect of FRAILTY. Frailty is more prevalent among 80 year olds but its not strictly a function of age. I do see robust 85 year olds and frail patients in their 60’s.

Expand full comment

Useful information for the physician who is looking for a reason to do something for the patient rather than an excuse to do something to the patient.

Expand full comment
Mar 27, 2023·edited Mar 27, 2023

“Translating trial results” is about the best job description there is for a practicing physician in the 21st century. He’s not the scientist, he’s not the trialist, and not the statistician. But this is what patients ask of him and trust him with and make life-and-death decisions based upon: this is the most noble endeavor of his day at work. Darn right humility is required, and dedication, study, sensitivity, discretion and intelligence. Tall order. The best doctors rise to it.

Expand full comment

The graphic of the Venn diagram with four competing "circles" is VERY useful in thinking through the upsides and downsides of any therapeutic tactic that may be applied for ANY given disease process. I just hung an enlargement of it on the wall here in my office. Thanks!

Expand full comment

Just as children are not really young adults, so too elderly adults are not like younger adults.

Expand full comment

I appreciate how you consistently state the need for humility in your articles. And how this study promotes the need to be humble to what medicine can do or should do for a patient. Or at least promotes honesty with one self and the patient with what a therapy can do to help or harm a specific population.

Expand full comment