Revascularisation or medical therapy in elderly patients with acute anginal syndromes (RINCAL) a randomised trial

Aims: To determine whether an intervention-guided strategy is superior to optimal medical therapy (OMT) for treating non-ST-elevation myocardial infarction (NSTEMI) in the elderly. Methods and results: Patients (=80 years, chest pain, ischaemic ECG, and elevated troponin) were randomised 1:1 to an invasive strategy plus OMT versus OMT alone. The combined primary endpoint was all-cause mortality and non-fatal myocardial re-infarction at 1 year. We enrolled 251 patients (n=125 invasive vs. n=126 conservative) from May 2014 to September 2018. Almost half were female. The trial was terminated prematurely due to slow recruitment. A Kaplan-Meier estimate of event-free survival revealed no difference in the primary combined endpoint (invasive 18.5% [23/124] vs. conservative 22.2% [28/126]; p=0.39) or in all-cause mortality alone (invasive 10.5% [13/124] vs. conservative 11.1% [14/126]; p=0.88). There was less angina at 3 months (p<0.001) in the intervention arm. Non-fatal reinfarction (invasive 9.7% [12/124] vs. conservative 14.3% [18/126]; p=0.22) and unplanned revascularisation (invasive 1.6% [2/124] vs. conservative 6.4% [8/126]; p=0.10) were non-significantly more frequent after OMT alone. Conclusion: The trial was underpowered to provide a definitive conclusion regarding the primary endpoint. An intervention-guided strategy did, however, result in less angina, reinfarction and unplanned revascularisation but did not improve survival.