Invasive treatment strategy for older patients with non-ST-elevation acute coronary syndrome: a systematic review and meta-analysis of randomized controlled trials

TL;DR

This study compares invasive and conservative treatments for older patients with a specific heart condition and finds that invasive treatment reduces heart attacks but increases bleeding risks.

Contribution

The study provides new evidence on treatment outcomes for older patients with non-ST-elevation acute coronary syndrome using randomized controlled trials.

Findings

Invasive management significantly decreased the risk of MI and revascularization.

Invasive treatment increased the incidence of severe bleeding compared to conservative management.

There was no significant difference in all-cause mortality or cardiovascular mortality between the two strategies.

Abstract

The optimal strategy for managing older patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) is uncertain. We aimed to compare the outcomes of invasive vs. conservative strategies for managing NSTE-ACS in older patients ≥65 years.

We systematically searched MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov, up to March 2025. We included randomized controlled trials (RCTs) comparing a routine invasive treatment strategy with conservative management alone in patients ≥65 years old with NTE-ACS. We pooled risk ratios (RRs) and hazard ratios (HRs) under a random-effects model.

We included 8 RCTs (3,887 patients). There was no significant difference between invasive and conservative management in the risk of a composite outcome of all-cause mortality or MI (RR 0.91, 95% CI: 0.79, 1.06; HR 0.88, 95% CI: 0.74, 1.05), and all-cause mortality (RR 1.05, 95% CI: 0.93, 1.17; HR 1.03, 95% CI: 0.90, 1.19). Invasive management significantly decreased the risk of MI (RR 0.70, 95% CI: 0.55, 0.89) and revascularization (RR 0.29, 95% CI: 0.21, 0.40). There was no significant difference between the two strategies in the risk of cardiovascular mortality (RR 1.09, 95% CI: 0.87, 1.35) and stroke (RR 0.77; 95% CI: 0.53, 1.12). Invasive management increased the incidence of severe bleeding (RR 1.43; 95% CI: 1.05, 1.94).

An invasive strategy in older patients with NSTE-ACS decreased the risk of MI and the need for revascularization. Future RCTs need longer follow-ups and should be conducted in ethnically diverse populations to enhance generalizability.

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024629566, PROSPERO CRD42024629566.

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