EVAOLDInterventional CardiologyOpen Access
Selective Versus Routine Invasive Management for NSTEMI in Elderly Patients
Evaluation of reperfusion strategies in elderly patients
Why the trial?
Older patients are underrepresented in the trials that defined reperfusion strategies for myocardial infarction, and comorbidity shifts the risk-benefit balance. EVAOLD evaluated reperfusion strategies specifically in elderly patients.
Does stress imaging-guided selective invasive management reduce death, myocardial infarction, or stroke compared to routine invasive management in patients aged 80 years or older hospitalised with NSTEMI?
Population
587 patients aged >=80 hospitalised with NSTEMI (of 1,756 planned)
Comparison
Stress imaging-guided selective invasive vs routine invasive management
Design
Open-label multicenter noninferiority trial (25 French centres); stopped for futility
Follow-up
1 year
Key result
Stress imaging-guided selective invasive management did not demonstrate noninferiority to routine invasive management for death, MI, or stroke (HR 1.22; 95% CI 0.86-1.72; p=0.27).
Authors
Discussion
Member takes
Where experts stand
Experts read EVAOLD as reinforcing routine invasive management for NSTEMI patients aged 80 and older, with the imaging-guided selective approach failing to meet noninferiority and the trial stopping early for futility.
EVAOLD tested whether older NSTEMI patients could safely skip routine catheterization in favor of stress imaging-guided selection, but the selective strategy could not match routine invasive care and the trial was halted for futility. Early reaction treats this as a signal that the default invasive approach holds even in the oldest patients. The open question is whether specific subgroups within this frail population might still benefit from a more selective pathway.
1 take classified by contention axis so far — the map appears as more land.
Still unclear
It remains unclear whether certain subgroups among patients 80 and older, such as those with higher frailty or comorbidity burden, might still benefit from an imaging-guided selective approach. Whether guidelines will further solidify routine invasive management as the standard for this age group based on a trial that stopped early with roughly a third of its planned enrollment is also unresolved.
Key expert perspectives
EVAOLD challenges the one-size-fits-all invasive approach in the oldest NSTEMI patients
Frames the trial as addressing an important clinical question: whether every NSTEMI patient aged 80 or older truly needs routine invasive management. Sees EVAOLD as a test of selective versus universal catheterization in this population.
Distilled from their postX post
GBGilles Barone-RochetteCardiologist, University Hospital of Grenoble, FranceResults readoutAug 31
Selective imaging-guided strategy reduced angiography but failed on major cardiovascular events
Although the stress imaging-guided selective strategy reduced the need for coronary angiography and angiography-related complications, it did not demonstrate noninferiority to routine invasive management for major cardiovascular events.
Distilled from their postOriginal post
Overview
Noninferiority of stress imaging-guided selective invasive management was not shown in elderly NSTEMI; supports routine invasive care while leaving selective strategies for further study.
Key Points
- To determine whether stress imaging-guided selective invasive management is noninferior to routine invasive management in patients aged 80 years or older hospitalized with NSTEMI.
- Open-label, multicenter noninferiority randomized trial across 25 French centers in patients aged ≥80 years hospitalized with NSTEMI (N=587 randomized of 1,756 planned).
- Assigned patients to stress imaging-guided selective invasive management or routine invasive management, evaluating a primary composite outcome of all-cause death, nonfatal myocardial infarction, or nonfatal stroke at one year.
- The trial was terminated early for futility after enrolling 587 patients due to low conditional power to demonstrate noninferiority.
- The primary endpoint occurred in 24.1% of the imaging-guided group versus 20.7% of the routine invasive group (HR 1.22, 95% CI 0.86 to 1.72; p=0.27), failing to demonstrate noninferiority.
- Selective management reduced overall angiography rates and angiography-related complications compared with routine invasive care.
Evidence details
What drove the result?
| Outcome | Selective | Routine |
|---|---|---|
| All-cause death, nonfatal MI, or nonfatal stroke at 1 year | 24.1% | 20.7% |
| Primary composite · HR 1.22 (95% CI 0.86-1.72); noninferiority not demonstrated (p=0.27) | ||
Limitations & tradeoffs
Safety
Angiography and angiography-related complications were reduced with the selective strategy (rates not reported).
Design limitations
Open-label design, stopped early for futility after 587 of 1,756 planned patients.
Statistical certainty
The wide CI (0.86–1.72) is compatible with meaningful harm from the selective strategy, and per-arm event counts and complication rates are not reported.
Structured PICO
Does stress imaging-guided selective invasive management reduce death, myocardial infarction, or stroke compared to routine invasive management in patients aged 80 years or older hospitalised with NSTEMI?
P
Population
587 patients aged 80 years or older hospitalized with NSTEMI, followed for one year.
I
Intervention
Stress imaging-guided selective invasive management
C
Comparator
Routine invasive management
O
Outcome
Composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke at one yearcomposite
In patients aged 80 years or older with NSTEMI, a stress imaging-guided selective invasive strategy failed to demonstrate noninferiority compared to routine invasive management for the composite of death, MI, or stroke at one year.
Main Result
Hazard Ratio: 1.22 (95% CI 0.86–1.72)
Absolute Event Rate: 24.1% vs 20.7%
p-value: p=0.27
Limitations
- Trial stopped early for futility after 587 of the planned 1,756 patients had been randomised because the conditional power to demonstrate noninferiority was low.
- Trial stopped early for futility
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Gilles Barone-Rochette (2026) conducted an RCT in NSTEMI (n=587). Stress imaging-guided selective invasive management vs. Routine invasive management was evaluated on Death from any cause, nonfatal myocardial infarction, or nonfatal stroke at one year (HR 1.22, 95% CI 0.86 to 1.72, p=0.27). Stress imaging-guided selective invasive management did not demonstrate noninferiority to routine invasive management for death, MI, or stroke (HR 1.22; 95% CI 0.86-1.72; p=0.27).