Invasive vs. conservative strategies in older patients with non-st-segment elevation myocardial infarction: an updated systematic review and meta-analysis

Abstract Background Non-ST-segment elevation myocardial infarction (NSTEMI) is a prevalent condition among older adults, yet the optimal management strategy remains uncertain. While invasive treatment approaches, including coronary angiography and revascularization, are recommended in younger populations, their benefits in older patients with increased frailty and comorbidities are debated. Purpose This systematic review and meta-analysis aimed to evaluate the efficacy and safety of invasive versus conservative treatment strategies in older patients (≥75 years) with NSTEMI. Methods We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials (RCTs) that compared invasive and conservative strategies in older NSTEMI patients. The primary outcome was a composite of cardiovascular death and nonfatal myocardial infarction. Secondary outcomes included all-cause mortality, stroke, recurrent myocardial infarction, and major bleeding. A random-effects model was used for meta-analysis, Statistical analysis was carried out utilizing R version 4.4.2. Heterogeneity was assessed with I² statistics; p-values inferior to 0.05 and I²25% were considered significant heterogeneity. Results This meta-analysis included 11 RCTs with 6,932 patients. The invasive strategy reduced the risk of recurrent myocardial infarction (OR 0.65; 95% CI: 0.56–0.75; p0.01; I²=25%) and revascularization (OR 0.31; 95% CI: 0.23–0.42; p0.001; I²=0%), but increased the risk of major bleeding (OR 1.79; 95% CI: 1.17–2.73; p0.01; I²=0%). No significant differences were observed between strategies for all-cause mortality (OR 0.99; 95% CI: 0.77–1.27; p=0.92; I²=24%), cardiovascular death (OR 1.14; 95% CI: 0.96–1.36; p=0.129; I²=0%), stroke recurrence (OR 0.96; 95% CI: 0.69–1.35; p=0.83; I²=0%), or hospitalization (OR 1.03; 95% CI: 0.62–1.74; p=0.89; I²=65.6%). Conclusions This systematic review and meta-analysis suggest that the invasive strategy reduced recurrent MI and revascularization but increased major bleeding, with no impact on mortality, stroke, or hospitalization. Treatment decisions should balance ischemic benefits and bleeding risks.