Early Invasive or Conservative Strategies for Older Patients With Acute Coronary Syndromes: A Meta-Analysis
Rohin K Reddy1,2, David Koeckerling3, Christian Eichhorn4
1National Heart and Lung Institute, Imperial College London, London, England.
JAMA Internal Medicine
|June 23, 2025
Summary
For older patients with acute coronary syndrome (ACS), an early invasive strategy did not reduce all-cause death but decreased recurrent myocardial infarction (MI) and revascularization. However, it increased major bleeding risk, requiring careful consideration in treatment decisions.
Area of Science:
- Cardiology
- Clinical Medicine
- Evidence-Based Medicine
Background:
- Optimal management for older patients with acute coronary syndrome (ACS) lacks robust randomized evidence.
- Recent large-scale, long-term randomized trials provide new data for this population.
Purpose of the Study:
- To evaluate the association between an early invasive strategy versus a conservative strategy and clinical outcomes in patients aged 70 years or older presenting with ACS.
Main Methods:
- Systematic literature search of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials up to October 2024.
- Inclusion of randomized trials comparing early invasive vs. conservative management in ACS patients ≥70 years.
- Meta-analysis of pooled data using fixed-effects and random-effects models to determine relative risks and hazard ratios.
Main Results:
- No significant difference in all-cause death between invasive and conservative strategies (RR, 1.05; 95% CI, 0.98-1.11).
- Early invasive strategy reduced recurrent myocardial infarction (MI) (RR, 0.78; 95% CI, 0.67-0.91) and repeated coronary revascularization (RR, 0.43; 95% CI, 0.30-0.60).
- Invasive strategy was associated with an increased risk of major bleeding (RR, 1.60; 95% CI, 1.01-2.53).
Conclusions:
- An early invasive strategy in older ACS patients does not improve all-cause mortality compared to conservative management.
- While reducing recurrent MI and revascularization, the invasive approach increases major bleeding risk.
- Shared decision-making should weigh the competing risks and benefits of invasive strategies for elderly ACS patients.
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