Key result
Invasive strategy fails to reduce death vs conservative care in older NSTE-ACS patients but reduces MI.
Why the study?
Non-ST segment elevation acute coronary syndromes are common in older patients, and evidence comparing invasive versus conservative management in this population needed synthesis.
Does an invasive treatment strategy reduce adverse clinical outcomes compared to conservative medical management in older patients (≥ 70 years) with NSTE-ACS?
Meta-Analysis (n=2,998)
Does an invasive treatment strategy reduce adverse clinical outcomes compared to conservative medical management in older patients (≥ 70 years) with NSTE-ACS?
Relative Risk: 1.03 (95% CI 0.92–1.15)
In older patients with NSTE-ACS, an invasive strategy reduces the risk of repeat myocardial infarction and unplanned revascularization without increasing major bleeding or stroke, though it does not improve mortality.
Invasive strategy offers no mortality benefit in older NSTE-ACS; confirms MI reduction without excess bleeding or stroke as the key advantage.
BACKGROUND: Non-ST segment elevation acute coronary syndromes (NSTE-ACS) are a common cause of hospital admission in older patients. Our study aims to synthesize the available evidence from randomized controlled trials (RCTs) to compare clinical outcomes with invasive versus conservative medical management in this population. METHODS: A literature search of online databases including PubMed/MEDLINE, Embase, and the Cochrane Library was conducted from inception to September 1, 2024. The search aimed to identify RCTs that reported clinical outcomes with invasive versus conservative strategies in older patients (≥ 70 years) with NSTE-ACS. The risk ratios (RRs) were used as summary estimates. RESULTS: Seven RCTs with 2998 patients were included; 1490 patients in the invasive group and 1508 patients in the conservatively managed group. The pooled analysis demonstrated no statistically significant difference between the two strategies for the risk of all-cause death (RR: 1.03, 95% CI: 0.92-1.15), cardiovascular death (RR: 1.04, 95% CI: 0.82-1.33), stroke (RR: 0.78, 95% CI: 0.53-1.15), and major bleeding (RR: 1.23, 95% CI: 0.90-1.69). However, the invasive strategy was associated with a significantly reduced risk of myocardial infarction (RR: 0.74, 95% CI: 0.57-0.96) and unplanned revascularization (RR: 0.29, 95% CI: 0.21-0.40) compared to the conservative strategy. CONCLUSION: In older patients with NSTE-ACS, an invasive strategy reduces the risk of repeat myocardial infarction and unplanned revascularization without a significant increase in stroke or major bleeding. There was no associated reduction in all-cause or cardiovascular mortality with the invasive strategy compared to conservative management.
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Ahmed et al. (2025) conducted a meta-analysis in Non-ST segment elevation acute coronary syndromes (NSTE-ACS) (n=2,998). Invasive treatment strategy vs. Conservative medical management was evaluated on All-cause death (RR 1.03, 95% CI 0.92-1.15). In older patients with NSTE-ACS, an invasive strategy did not reduce all-cause death (RR 1.03; 95% CI 0.92-1.15) compared to conservative management, but reduced myocardial infarction.
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