Invasive Treatment Strategy for Older Patients with Non-ST-Elevation Acute Coronary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Vaibhav Vats¹Rai Dilawar Shahjehan²Sharanya Bavurothu Kumar³SANAPALA KEERTHI³Kartik Mittal⁴Carlos Andres Barba Herazo⁵Seema Nabil Nimer⁶Raparthi Aishwarya⁷Jasneet K Arora⁸Nikhil Kumar Balagoni⁹Alaa Hamza Hermis¹⁰Rawaa M Mohammad¹⁰Huzaifa Ahmad Cheema^11*Bilawal Nadeem¹²Muhammad Aslam Khan¹³Saad Ur Rehman¹⁴Raheel Ahmed^15*

• ¹Albert Einstein College of Medicine, New York, United States
• ²Ochsner Heart and Vascular Institute, New Orleans, United States
• ³King George Hospital, Visakhapatnam, India
• ⁴Samarth Clinic for Healthy Aging, Gurugram, India
• ⁵Fundacio Hospital d'Olot i Comarcal de la Garrotxa, Olot, Spain
• ⁶The University of Jordan School of Medicine, Amman, Jordan
• ⁷Andhra Medical College, Visakhapatnam, India
• ⁸All Saints University School of Medicine, Roseau, Dominica
• ⁹Osmania Medical College, Hyderabad, India
• ¹⁰Al-Mustaqbal University, Hillah, Iraq
• ¹¹King Edward Medical University, Lahore, Pakistan
• ¹²Boston Medical Center, Boston, United States
• ¹³Guthrie Robert Packer Hospital, Sayre, United States
• ¹⁴Lahey Hospital and Medical Center, Burlington, United States
• ¹⁵Imperial College London, London, United Kingdom

Abstract Background: The optimal strategy for managing older patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) is uncertain. We aimed to compare the outcomes of invasive versus conservative strategies for managing NSTE-ACS in older patients ≥ 65 years. Methods: We systematically searched MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov, up to March 2025. We included randomized controlled trials (RCTs) comparing a routine invasive treatment strategy with conservative management alone in patients ≥ 65 years old with NTE-ACS. We pooled risk ratios (RRs) and hazard ratios (HRs) under a random-effects model. Results: We included 8 RCTs (3887 patients). There was no significant difference between invasive and conservative management in the risk of a composite outcome of all-cause mortality or MI (RR 0.91, 95% CI: 0.79,1.06; HR 0.88, 95% CI: 0.74, 1.05), and all-cause mortality (RR 1.05, 95% CI: 0.93, 1.17; HR 1.03, 95% CI: 0.90, 1.19). Invasive management significantly decreased the risk of MI (RR 0.70, 95% CI: 0.55, 0.89) and revascularization (RR 0.29, 95% CI: 0.21, 0.40). There was no significant difference between the two strategies in the risk of cardiovascular mortality (RR 1.09, 95% CI: 0.87, 1.35) and stroke (RR 0.77; 95% CI: 0.53, 1.12). Invasive management increased the incidence of severe bleeding (RR 1.43; 95% CI: 1.05, 1.94). Conclusions: An invasive strategy in older patients with NSTE-ACS decreased the risk of MI and the need for revascularization. Future RCTs need longer follow-ups and should be conducted in ethnically diverse populations to enhance generalizability.