What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Non-ST-elevation acute coronary syndrome (NSTE-ACS) (n=4114). Intervention: Invasive strategy vs. Conservative strategy. Primary outcome: All-cause mortality (RR 1.04, 95% CI 0.98-1.11, p=0.18).

February 13, 2025Open Access

Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials

Key Result

In elderly patients with NSTE-ACS, an invasive strategy did not significantly impact all-cause mortality (RR 1.04) compared to conservative management, but reduced revascularization needs.

Study Design

Type

Meta-Analysis (n=4,114)

Multicenter

Yes

Structured PICO

Does an invasive strategy improve all-cause and cardiovascular mortality compared to a conservative strategy in elderly patients (≥ 70 years) with NSTE-ACS?

Population

11 RCTs pooling 4,114 elderly patients (≥ 70 years) with non-ST-elevation acute coronary syndrome (NSTE-ACS). Approximate mean age over 80. Multinational (European and North American countries).

Intervention

Invasive strategy (optimal medical therapy + invasive coronary angiography ± coronary revascularization [PCI/CABG] based on findings).

Comparator

Conservative strategy (optimal medical therapy ± invasive coronary angiography if indicated for refractory symptoms/clinical deterioration ± coronary revascularization).

Outcome

Co-primary outcomes: all-cause mortality and cardiovascular mortality.hard clinical

In elderly patients with NSTE-ACS, an invasive strategy reduces revascularization needs and MI risk but increases bleeding risk without providing a survival benefit.

Main Result

Effect estimate: RR 1.04 (95% CI 0.98-1.11)

p-value: p=0.18

Limitations

Variation in age thresholds defining elderly across trials
Heterogeneity in bleeding outcome definitions
Open-label design of included trials with crossover between arms
Premature termination of some trials due to recruitment challenges

Abstract

BACKGROUND: Advances in managing non-ST-elevation acute coronary syndrome (NSTE-ACS) have yet to clarify the optimal treatment for elderly patients, whose complex health profiles and underrepresentation in trials add challenges to decision-making. METHODS: We systematically searched PubMed, Embase, Web of Science, and Scopus for randomized controlled trials comparing invasive versus conservative strategies in elderly patients (≥ 70 years) with NSTE-ACS through October 2024. Co-primary outcomes were all-cause and cardiovascular mortalities, with secondary outcomes including myocardial infarction (MI), revascularization, stroke, decompensated heart failure, and bleeding events. Outcomes were analyzed using both risk ratios (RR) and hazard ratios (HR). RESULTS: Analysis of 11 trials (4,114 patients) showed no significant differences in all-cause mortality (RR: 1.04, 95% CI: 0.98-1.11; HR: 1.10, 95% CI: 0.94-1.29) or cardiovascular mortality (RR: 0.98, 95% CI: 0.85-1.12; HR: 0.94, 95% CI: 0.73-1.20) between strategies. The invasive approach significantly reduced subsequent revascularization (RR: 0.41, 95% CI: 0.27-0.62; HR: 0.30, 95% CI: 0.19- 0.47; p < 0.01 in both analyses) and MI risk (RR: 0.75, 95% CI: 0.57-0.99, p = 0.04; HR: 0.64, 95% CI: 0.49-0.83, p < 0.01), though with some levels of heterogeneity in sensitivity analyses for MI. Stroke and heart failure outcomes were comparable between strategies. However, it significantly increased the risk of both composite major and minor bleeding risk (RR: 1.50, 95% CI: 1.02-2.20, p = 0.04) and major bleeding alone (RR: 1.92, 95% CI: 1.04-3.56, p = 0.04). CONCLUSION: In elderly patients with NSTE-ACS, an invasive strategy reduces revascularization needs and, potentially, MI risk without impacting survival, but at the cost of increased bleeding risk. This supports individualized treatment decisions based on patient-specific characteristics, particularly bleeding risk and geriatric factors.

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