Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2024 Nov 5;13(21):e036151.
doi: 10.1161/JAHA.124.036151. Epub 2024 Nov 4.

Invasive Versus Conservative Strategy in Older Adults ≥75 Years of Age With Non-ST-segment-Elevation Acute Coronary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Amit Rout  1 , Mohamad B Moumneh  2 , Kriti Kalra  2 , Sahib Singh  3 , Aakash Garg  4 , Vijay Kunadian  5   6 , Simone Biscaglia  7 , Mohamad A Alkhouli  8 , Jennifer A Rymer  9   10 , Wayne B Batchelor  2 , Michael G Nanna  11 , Abdulla A Damluji  2   12
Affiliations
Meta-Analysis

Invasive Versus Conservative Strategy in Older Adults ≥75 Years of Age With Non-ST-segment-Elevation Acute Coronary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Amit Rout et al. J Am Heart Assoc. .

Abstract

Background: Older adults with non-ST-segment-elevation acute coronary syndrome are less likely to undergo an invasive strategy compared with younger patients. Randomized controlled trials traditionally exclude older adults because of their high burden of geriatric conditions.

Methods and results: We searched for randomized controlled trials comparing invasive versus medical management or a selective invasive (conservative) strategy for older patients (age≥75 years) with non-ST-segment-elevation acute coronary syndrome. Fixed effects meta-analysis was conducted to estimate the odds ratio (OR) with 95% CI for the composite of death or myocardial infarction (MI) and individual secondary end points of all-cause death, cardiovascular death, MI, revascularization, stroke, and major bleeding. Nine studies with 2429 patients (invasive: 1228 versus control: 1201) with a mean follow-up of 21 months were included. An invasive strategy was associated with a significantly decreased risk of a composite of death and MI (OR, 0.67 [95% CI, 0.54-0.83], P<0.001), MI (OR, 0.56 [95% CI, 0.45-0.70], P<0.001) and subsequent revascularization (OR, 0.27 [95% CI, 0.16-0.48], P<0.001). There was no difference in all-cause death (OR, 0.84 [95% CI, 0.65-1.10], P=0.21), cardiovascular death (OR, 0.85 [95% CI, 0.63-1.15], P=0.30), stroke (OR, 0.74 [95% CI, 0.38-1.47], P=0.39), or major bleeding (OR, 1.24 [95% CI, 0.42-3.66], P=0.70).

Conclusions: In older patients ≥75 years old with non-ST-segment-elevation acute coronary syndrome, an invasive strategy reduced the risk of a composite of death and MI, MI, and subsequent revascularization compared with a conservative strategy alone. Older adults with higher burden of geriatric conditions should be included in future trials to improve generalizability to this growing population.

Keywords: aged; coronary disease; geriatric assessment; meta‐analysis; percutaneous coronary intervention.

PubMed Disclaimer

Figures

Figure 1
Figure 1. PRISMA flow diagram.
PRISMA indicates Preferred Reporting Items for Systematic Reviews and Meta‐Analyses; and RCT, randomized controlled trial.
Figure 2
Figure 2. Plots presenting odds ratios and 95% CIs for the comparison of participants in the invasive group vs the conservative group using the fixed‐effects models with the Mantel–Haenszel method.
A, Forest plot illustrating the odds ratio for death or myocardial infarction, , , , ; B, Forest plot illustrating the odds ratio for myocardial infarction, , , , , ; C, Forest plot illustrating the odds ratio for all‐cause death, , , , , ; D, Forest plot illustrating the odds ratio for cardiovascular death., , ACS indicates acute coronary syndrome; df, degrees of freedom; FIR, Fast Revascularization During Instability in Coronary Artery Disease; I2, inconsistency factor; M‐H, Mantel–Haenszel; MOSCA, Comorbilidades en el Síndrome Coronario Agudo; MOSCA‐FRAIL, Comorbilidades en el Síndrome Coronario Agudo–Invasive and Conservative Strategies in Elderly Frail Patients With Non‐STEMI; RINCAL, Revascularisation or Medical Therapy in Elderly Patients With Acute Anginal Syndromes; and TACTICS TIMI 18, Treat Angina With Aggrastat and Determine Cost of Therapy With an Invasive or Conservative Strategy–Thrombolysis in Myocardial Infarction 18.
Figure 3
Figure 3. Plots presenting odds ratios and 95% CIs for the comparison of participants in the invasive group vs the conservative group using the fixed‐effects models with the Mantel–Haenszel method.
A, Forest plot illustrating the odds ratio for repeat revascularization, , , ; B, Forest plot illustrating the odds ratio for stroke, , , , ; C, Forest plot illustrating the odds ratio for major bleeding., , , , ACS indicates acute coronary syndrome; df, degrees of freedom; I2, inconsistency factor; M‐H, Mantel–Haenszel; MOSCA, Comorbilidades en el Síndrome Coronario Agudo; RINCAL, Revascularisation or Medical Therapy in Elderly Patients With Acute Anginal Syndromes; and TACTICS TIMI 18, Treat Angina With Aggrastat and Determine Cost of Therapy With an Invasive or Conservative Strategy–Thrombolysis in Myocardial Infarction 18.
See this image and copyright information in PMC

References

    1. The Older Population in the United States: 2019. Accessed January 11, 2023. https://www.census.gov/data/tables/2019/demo/age‐and‐sex/2019‐older‐popu....
    1. Odden MC, Coxson PG, Moran A, Lightwood JM, Goldman L, Bibbins‐Domingo K. The impact of the aging population on coronary heart disease in the United States. Am J Med. 2011;124:827–833. doi: 10.1016/j.amjmed.2011.04.010 - DOI - PMC - PubMed
    1. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, Van de Werf F, White HD, Weaver WD, Naylor MD, et al. Acute coronary care in the elderly, part I: non‐ST‐segment‐elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on clinical cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115:2549–2569. doi: 10.1161/circulationaha.107.182615 - DOI - PubMed
    1. De Luca L, Olivari Z, Bolognese L, Lucci D, Gonzini L, Di Chiara A, Casella G, Chiarella F, Boccanelli A, Di Pasquale G, et al. A decade of changes in clinical characteristics and management of elderly patients with non‐ST elevation myocardial infarction admitted in Italian cardiac care units. Open Heart. 2014;1:e000148. doi: 10.1136/openhrt-2014-000148 - DOI - PMC - PubMed
    1. Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL II, DeVon HA, Alexander KP. Management of Acute Coronary Syndrome in the older adult population: a scientific statement from the American Heart Association. Circulation. 2023;147:e32–e62. doi: 10.1161/cir.0000000000001112 - DOI - PMC - PubMed

MeSH terms

LinkOut - more resources