Key result
Invasive strategy cuts unplanned revascularization ~64% and reduces MI vs conservative management in older NSTE-ACS.
Why the study?
Older adults are often underrepresented in clinical trials due to frailty and comorbidities, making the choice between invasive and conservative management for NSTE-ACS controversial.
Does an invasive management strategy reduce adverse cardiovascular events compared to a conservative strategy in older adults with NSTE-ACS?
Meta-Analysis (n=2,997)
Does an invasive management strategy reduce adverse cardiovascular events compared to a conservative strategy in older adults with NSTE-ACS?
In older adults with NSTE-ACS, an invasive strategy reduces the risk of subsequent MI and unplanned revascularization without significantly increasing major bleeding or mortality.
Reduces MI and unplanned revascularization without excess bleeding or mortality in older NSTE-ACS; confirms benefit on key secondary endpoints despite neutral primary composite.
Non-ST-elevation acute coronary syndrome (NSTE-ACS) is a common condition among older adults. However, due to frailty and comorbidities, older adults are often underrepresented in clinical trials, making the decision between an invasive or conservative approach for optimal management controversial. Our meta-analysis seeks to address this issue by focusing exclusively on randomized controlled trials (RCTs). A systematic database literature search was conducted via PubMed, the Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov to identify RCTs comparing invasive and conservative management strategies in older adults with NSTE-ACS. Data on unplanned revascularization, myocardial infarction (MI), bleeding, all-cause mortality, composite of major adverse outcomes, and stroke were extracted and pooled. Random-effects models to calculate pooled risk ratios (RR) with 95% confidence intervals (CI) were analyzed using the Review Manager software. A total of seven RCTs and a total of 2997 patients were included in the meta-analysis. The invasive approach demonstrated a lower risk of unplanned revascularization (RR: 0.36; 95% CI: 0.23, 0.55; p < 0.00001; I² = 28%) and MI (RR: 0.72; 95% CI: 0.56, 0.94; p = 0.01; I² = 34%). No significant differences were found for major bleeding episodes (RR: 1.40; 95% CI: 0.93, 2.14; p = 0.11), all-cause mortality (RR: 1.01; 95% CI: 0.91, 1.12; p = 0.49), composite of major adverse events (RR: 0.87; 95% CI: 0.73, 1.05; p = 0.14) and risk of stroke (RR: 0.84; 95% CI: 0.59, 1.20; p = 0.34) between the two strategies. Our findings reveal that, in older adults with NSTE-ACS, an invasive strategy reduces the risk of subsequent MI and unplanned revascularization. However, no significant differences in mortality, bleeding, or stroke were observed between the two groups.
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Goyal et al. (2025) conducted a meta-analysis in Non-ST-elevation acute coronary syndrome (NSTE-ACS) (n=2,997). Invasive strategy vs. Conservative strategy was evaluated on Unplanned revascularization (RR 0.36, 95% CI 0.23-0.55, p=< 0.00001). In older adults with NSTE-ACS, an invasive strategy reduced the risk of unplanned revascularization (RR 0.36; 95% CI 0.23-0.55) and MI (RR 0.72; 95% CI 0.56-0.94) versus conservative management.
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