Invasive versus conservative strategy in older adults ≥70 years of age with non-ST-segment-elevation myocardial infarction: a GRADE-assessed systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

Older adults with Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) are often undertreated invasively due to concerns about risks and comorbidities, despite potential benefits. Their limited inclusion in clinical trials leaves a gap in evidence-based management. This meta-analysis compared invasive versus conservative strategies in elderly NSTEMI patients.

A systematic search was conducted across PubMed, CENTRAL, Web of Science, Scopus, and Embase through December 2024. Pooled results were reported using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes with 95% confidence intervals (CI).

A total of 11 randomized controlled trials involving 4114 patients were included. Invasive treatment significantly reduced the composite of all-cause mortality and non-fatal MI (RR: 0.82; 95% CI: 0.68-0.99; p = 0.04) and MI alone (RR: 0.68; 95% CI: 0.56-0.84; p = 0.0003). There was no significant difference in all-cause mortality (RR: 1.04; 95% CI: 0.92-1.16; p = 0.55) or cardiovascular death (RR: 0.96; 95% CI: 0.78-1.18; P = 0.67). Invasive strategy significantly lowered the need for revascularization (RR: 0.29; 95% CI: 0.21-0.40; p < 0.0001).

In NSTEMI patients aged ≥70, invasive management reduces the risk of MI and revascularization without increasing mortality risk. More elderly-focused trials are warranted.

https://www.crd.york.ac.uk/prospero identifier is CRD42025633157.