Routine invasive vs. conservative strategy in elderly patients with non-ST-elevation acute coronary syndrome
Carlos Diaz-Arocutipa1, Rafael Salguero2,3, Roberto Martín-Asenjo2,3
1Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru.
Expert Review of Cardiovascular Therapy
|July 3, 2025
Summary
For elderly patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), a routine invasive strategy effectively lowers cardiovascular events. This approach reduces major adverse cardiovascular events and myocardial infarction without increasing bleeding risk, supporting personalized care.
Area of Science:
- Cardiology
- Geriatric Medicine
- Interventional Cardiology
Background:
- Optimal management for elderly patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is not well-defined.
- This systematic review addresses the uncertainty surrounding routine invasive versus conservative strategies in this demographic.
Purpose of the Study:
- To systematically review and assess the efficacy and safety of routine invasive versus conservative management strategies in elderly patients diagnosed with NSTE-ACS.
- To provide evidence to support individualized treatment decisions for this vulnerable patient population.
Main Methods:
- A systematic search of PubMed, Embase, and Scopus was conducted for randomized controlled trials (RCTs) published up to September 2024.
- Seven RCTs involving 2,997 elderly patients (mean age 81-86 years) were included in the meta-analysis.
- Random-effects models were used, with major adverse cardiovascular events (MACE) as the primary outcome and mortality, myocardial infarction, revascularization, stroke, and bleeding as secondary outcomes. Evidence certainty was assessed using GRADE.
Main Results:
- Routine invasive strategy significantly reduced the risk of MACE (HR 0.77, 95% CI 0.65-0.92) in elderly NSTE-ACS patients.
- Significant reductions were observed in myocardial infarction (HR 0.70) and revascularization (HR 0.45).
- No significant differences were found in all-cause mortality, cardiovascular mortality, stroke, or bleeding events between the strategies. Evidence certainty was generally moderate.
Conclusions:
- A routine invasive strategy is beneficial for elderly patients with NSTE-ACS, leading to reduced cardiovascular events.
- This strategy does not appear to significantly increase the risk of bleeding, supporting its consideration in clinical practice.
- Findings support the need for individualized treatment decisions based on patient-specific factors and risk profiles.
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