CLINICAL QUESTION: In patients aged 70 years or older with non–ST-segment elevation acute coronary syndrome (NSTEACS), does an invasive strategy reduce mortality and cardiovascular events compared with conservative management?
BACKGROUND: The optimal management of NSTEACS in older adults remains controversial. While invasive strategies have demonstrated benefit in younger populations, older adults are frequently underrepresented in randomized trials and often have a higher burden of comorbidities and frailty.
STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials conducted in Europe
SYNOPSIS: This meta-analysis included seven randomized controlled trials comprising 2,998 patients aged 70 years or older with NSTE-ACS, comparing an invasive strategy (coronary angiography with revascularization at the treating physician’s discretion) with a conservative strategy. Conservative management was not protocolized and varied across studies, reflecting contemporaneous clinical practice and guideline recommendations at the time of each trial. Mean participant age ranged from 81 to 86 years, with follow-up of up to 4.1 years. No significant differences between strategies were observed in all-cause or cardiovascular mortality. The invasive strategy was associated with a significant reduction in myocardial infarction (relative risk [RR], 0.74; 95% CI, 0.57 to 0.96) and unplanned revascularization (RR, 0.29; 95% CI, 0.21 to 0.40), with moderate certainty of evidence due to study heterogeneity. A small reduction in stroke risk was observed (RR, 0.78; 95% CI, 0.53 to 1.15), with moderate certainty due to imprecision, without a significant increase in major bleeding. Very frail and institutionalized patients were excluded from the trials, limiting generalizability.
BOTTOM LINE: In older adults with NSTE-ACS, an invasive strategy likely reduces recurrent myocardial infarction, unplanned revascularization, and possibly stroke, but does not improve survival, underscoring the need for individualized, patient-centered decision making.
CITATION: Ahmed M, et al. Invasive versus conservative treatment strategy in older patients with non-ST segment elevation acute coronary syndromes: a meta-analysis of randomized controlled trials. J Am Geriatr Soc. 2025;73(7):2238-2246. doi: 10.1111/jgs.19447.
Dr. Furlong is a hospitalist at the clinical medicine department at Hospital Aleman and an instructor of internal medicine at the University of Salvador, both in Buenos Aires, Argentina.