Routine Invasive vs Conservative Management of NSTEMI in Elderly Patients: Updated Meta-Analysis of Randomized Trials

Decision-making on managing non-ST-segment elevation myocardial infarction (NSTEMI) with routine invasive strategy or conservatively in elderly patients remains a question of much debate, given that these patients are often under-represented in clinical trials.

In patients aged 70 years or more, is routine invasive strategy superior to conservative management of NSTEMI?

We systematically reviewed multiple online databases to identify randomized controlled trials that evaluated the outcomes of invasive vs conservative strategies for NSTEMI in patients aged over 70 years. An inverse-variance weighting, frequentist meta-analysis was performed on data extracted from eligible studies.

A total of 8 randomized controlled trials involving 3,275 patients (49.7% invasive-treated and 50.3% conservative-treated) were included. Routine invasive strategy was not superior to conservative management in elderly patients with NSTEMI in all-cause mortality (OR: 1.07; 95% CI: 0.90-1.26; P = 0.44; I²: 0%) and cardiac-related death (OR: 1.05; 95% CI: 0.86-1.29; P = 0.64; I²: 0%). Routine invasive strategy, however, confers significant benefits in reducing the risk of myocardial reinfarction (OR: 0.71; 95% CI: 0.58-0.86; P = 0.0005; I²: 34%) and urgent revascularization (OR: 0.31; 95% CI: 0.23-0.42; P < 0.00001; I²: 0%) without predisposing NSTEMI patients aged ≥70 years to increased susceptibility to cerebrovascular accident (OR: 1.13; 95% CI: 0.82-1.55; P = 0.45; I²: 0%).

In elderly patients with NSTEMI, routine invasive strategy does not improve primary outcomes of all-cause mortality or cardiac-related death but may reduce recurrent myocardial infarction and the need for urgent revascularization.