Key result
Invasive management in nonagenarians with ACS cuts in-hospital mortality ~43% vs conservative care.
Why the study?
Nonagenarians with ACS are frequently underrepresented in clinical trials, leading to uncertainty regarding optimal management when balancing guideline-recommended invasive strategies against concerns over frailty, comorbidities, and procedural risk.
Does an invasive management strategy including percutaneous coronary intervention reduce in-hospital and long-term mortality compared with conservative management in nonagenarians with acute coronary syndrome?
Meta-Analysis (n=1,138,508)
Does an invasive management strategy including percutaneous coronary intervention reduce in-hospital and long-term mortality compared with conservative management in nonagenarians with acute coronary syndrome?
In nonagenarians with acute coronary syndrome, an invasive management strategy is associated with a 43% reduction in in-hospital mortality and a 38% reduction in long-term mortality compared with conservative management, suggesting advanced age alone should not preclude invasive care.
Invasive strategy may be considered in nonagenarians with ACS; leaves open confirmation in randomized trials.
Background Nonagenarians with acute coronary syndrome (ACS) are frequently underrepresented in clinical trials, leading to uncertainty regarding the optimal management strategy. While invasive management is guideline-recommended for ACS, concerns regarding frailty, comorbidities, and procedural risk often lead to a conservative approach in this very elderly population. Purpose To evaluate the impact of an invasive strategy compared with a conservative strategy on in-hospital and long-term mortality among nonagenarians presenting with ACS. Methods A systematic review and meta-analysis were conducted in 3 databases (Pubmed, Scopus, Web of Science) assessing studies that compared an invasive strategy that included percutaneous coronary intervention versus conservative management in patients aged ≥90 years with ACS. The primary outcomes were in-hospital mortality and long-term mortality. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Statistical heterogeneity was assessed using the I² statistic. Results Database search yielded 1289 studies. After removal of duplicates and title/abstract screening, the full text of 74 manuscripts was assessed. Ultimately, 12 studies were included for data extraction. Nine studies comprising 1,902 nonagenarians (881 invasive, 1,021 conservative) were assessed in-hospital mortality. An invasive strategy was associated with a significant reduction in in-hospital mortality compared with conservative management (RR 0.57, 95% CI 0.43–0.75; p = 0.0016), with considerable heterogeneity (I² = 73.9%). Ten studies including 1,138,508 patients (98,829 invasive, 1,039,679 conservative) contributed to the long-term mortality analysis. Invasive management was associated with significantly lower long-term mortality (RR 0.62, 95% CI 0.49–0.77; p = 0.0009), with substantial between-study heterogeneity (I² = 93.8%). Conclusion Among nonagenarians with ACS, an invasive strategy is associated with significantly lower in-hospital and long-term mortality compared with conservative management. Despite substantial heterogeneity, these findings suggest that advanced age alone should not preclude consideration of invasive management in carefully selected nonagenarian patients.
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Vlachakis et al. (2026) conducted a meta-analysis in Acute coronary syndrome (n=1,138,508). Invasive management strategy (including percutaneous coronary intervention) vs. Conservative management was evaluated on In-hospital mortality and long-term mortality (RR 0.57, 95% CI 0.43-0.75, p=0.0016). Invasive management in nonagenarians with ACS lowered in-hospital (RR 0.57, 95% CI 0.43-0.75) and long-term mortality (RR 0.62, 95% CI 0.49-0.77) vs conservative care.
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