What are the implications of the Senior RITA (Research Investigating Therapeutic Approaches) trial 2025 on cardiovascular health management?

Senior RITA Trial 2025: Key Findings and Clinical Implications

Primary Trial Results

The BHF SENIOR-RITA trial demonstrated that in older adults (≥75 years) with NSTEMI, an invasive strategy of coronary angiography and revascularization did not significantly reduce the composite primary outcome of cardiovascular death or nonfatal myocardial infarction compared to a conservative medical therapy strategy over 4.1 years of follow-up. 1

Trial Design and Population

• The trial enrolled 1,518 patients aged 75 years or older (mean age 82 years) with NSTEMI across 48 UK sites 1
• 45% were women and notably, 32% were frail—a population typically excluded from cardiovascular trials 1
• Patients were randomized 1:1 to invasive strategy (angiography + revascularization + medical therapy) versus conservative strategy (medical therapy alone) 1

Primary Outcome Results

• No significant difference in the composite primary endpoint: 25.6% in the invasive group versus 26.3% in the conservative group (HR 0.94,95% CI 0.77-1.14, p=0.53) 1
• Cardiovascular death occurred in 15.8% (invasive) versus 14.2% (conservative), showing no benefit and a trend toward harm (HR 1.11,95% CI 0.86-1.44) 1
• Nonfatal MI was reduced in the invasive group: 11.7% versus 15.0% (HR 0.75,95% CI 0.57-0.99) 1
• Procedural complications occurred in less than 1% of patients 1

Clinical Implications for Practice

When to Consider Conservative Management in Older Adults

For patients ≥75 years with NSTEMI, particularly those who are frail or have high comorbidity burden, a conservative strategy of optimal medical therapy alone is a reasonable and evidence-based approach that does not compromise survival. 1

This represents a paradigm shift because:

• Previous trials excluded frail elderly patients, making SENIOR-RITA the first to demonstrate safety of conservative management in this vulnerable population 1
• The invasive strategy showed no mortality benefit despite being performed safely with low complication rates 1
• The reduction in nonfatal MI with invasive strategy must be weighed against no survival benefit and patient preferences regarding invasive procedures 1

Integration with Current Guidelines

The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guidelines for acute coronary syndromes emphasize multivessel PCI benefits in STEMI patients with multivessel disease, but these recommendations apply to hemodynamically stable patients with anatomy suitable for PCI and without clinical factors precluding invasive therapy 2. The SENIOR-RITA findings suggest that age ≥75 years, frailty, and NSTEMI presentation should prompt careful consideration of conservative management rather than automatic invasive intervention. 1

Practical Decision-Making Algorithm

For older adults (≥75 years) presenting with NSTEMI:

1. Assess frailty status and comorbidity burden - 32% of SENIOR-RITA patients were frail, representing real-world elderly populations 1

2. If patient is frail or has high comorbidity burden:

   • Conservative medical therapy is appropriate as first-line strategy 1
   • Focus on optimal medical management including antiplatelet therapy, statins, beta-blockers, and ACE inhibitors/ARBs 1
   • Reserve invasive strategy for refractory symptoms or hemodynamic instability 1

3. If patient is non-frail with good functional status:

   • Shared decision-making regarding invasive versus conservative approach 1
   • Discuss that invasive strategy may reduce recurrent MI but does not improve survival 1
   • Consider patient preferences regarding procedural intervention versus medical management 1

Important Caveats

• This trial specifically studied NSTEMI, not STEMI - the benefits of immediate revascularization in STEMI remain well-established and should not be extrapolated to SENIOR-RITA findings 2, 1
• The trial excluded patients intended for CABG and those with complex left main disease 2
• Median follow-up was 4.1 years; longer-term outcomes beyond this timeframe are unknown 1

Contrast with Historical RITA Trials

The original RITA-1 trial (1998) compared PTCA versus CABG in younger populations and found similar long-term survival but higher reintervention rates with PTCA 3. RITA-2 (2003) showed PTCA improved symptoms but not mortality in medically managed patients 4. SENIOR-RITA extends this evidence base specifically to the elderly NSTEMI population, demonstrating that conservative management is a valid option when invasive intervention may not provide survival benefit. 1