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The following is a summary of “Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials,” published in the February 2025 issue of the BMC Cardiovascular Disorders by Kohansal et al.

Despite significant advancements in the management of non-ST-elevation acute coronary syndrome (NSTE-ACS), the optimal treatment approach for older patients remains uncertain. Older adults present unique clinical challenges due to age-related comorbidities, increased bleeding risk, and their historical underrepresentation in clinical trials. This study aims to evaluate the efficacy and safety of invasive versus conservative management strategies in older patients with NSTE-ACS, focusing on key clinical outcomes, including mortality, MI, revascularization, stroke, heart failure, and bleeding events.

A comprehensive systematic review and meta-analysis were conducted by searching PubMed, Embase, Web of Science, and Scopus for randomized controlled trials (RCTs) comparing invasive and conservative strategies in older adults (≥70 years) with NSTE-ACS. Studies published up to October 2024 were included, and outcome measures were analyzed using both RR and HR. The co-primary endpoints were all-cause mortality and cardiovascular mortality, while secondary endpoints included MI, need for revascularization, stroke, decompensated heart failure, and bleeding complications.

A total of 11 RCTs encompassing 4,114 patients were included in the analysis. No significant differences were observed in all-cause mortality (RR: 1.04, 95% CI: 0.98–1.11; HR: 1.10, 95% CI: 0.94–1.29) or cardiovascular mortality (RR: 0.98, 95% CI: 0.85–1.12; HR: 0.94, 95% CI: 0.73–1.20) between the invasive and conservative approaches. However, an invasive strategy was associated with a significantly lower risk of subsequent revascularization (RR: 0.41, 95% CI: 0.27–0.62; HR: 0.30, 95% CI: 0.19–0.47; p < 0.01 in both analyses) and MI (RR: 0.75, 95% CI: 0.57–0.99, p = 0.04; HR: 0.64, 95% CI: 0.49–0.83, p < 0.01), although some heterogeneity was noted in sensitivity analyses for MI outcomes. There were no significant differences in stroke or decompensated heart failure between the two strategies.

However, the invasive approach was associated with a significantly higher risk of bleeding complications. The composite risk of major and minor bleeding events was increased (RR: 1.50, 95% CI: 1.02–2.20, p = 0.04), and the risk of major bleeding alone was nearly doubled (RR: 1.92, 95% CI: 1.04–3.56, p = 0.04). These findings underscore the trade-off between the benefits of an invasive approach in reducing MI and revascularization rates and its potential harm due to increased bleeding risk, which is particularly concerning in older patients.

In conclusion, while an invasive strategy in older adults with NSTE-ACS does not improve overall survival or cardiovascular mortality, it significantly reduces the need for future revascularization and potentially lowers MI risk. However, this benefit comes at the cost of increased bleeding complications. These findings emphasize the need for individualized treatment decisions that take into account patient-specific factors such as bleeding risk, frailty, and overall health status. Future research should focus on refining risk stratification tools to optimize treatment selection for older adults with NSTE-ACS, ensuring a balance between therapeutic efficacy and safety.

Source: bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-025-04560-8