Invasive Versus Conservative Management Among Older Adult Patients With Non–ST‐Segment–Elevation Myocardial Infarction: A Meta‐Analysis of Randomized Controlled Trials

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Background Older adult patients have been underrepresented in the pivotal trials comparing an invasive versus conservative management for non–ST‐segment–elevation myocardial infarction (NSTEMI). Methods We performed an electronic search of MEDLINE, Embase, and Cochrane databases through September 2024 for randomized controlled trials comparing invasive versus conservative management of NSTEMI in patients aged ≥70 years. Results The final analysis included 7 randomized controlled trials with 2997 patients. The weighted mean follow‐up time was 47.1 months, and the mean age was 82.6 years. There was no significant difference in all‐cause mortality between an invasive versus a conservative management approach (27.9% versus 26.6%; risk ratio [RR], 1.05 [95% CI, 0.94–1.18]; I 2 =0%). There was a statistically nonsignificant trend for fewer major adverse cardiac events in the invasive group (28.3% versus 33.4%; RR, 0.82 [95% CI, 0.68–1.00]; P =0.05, I 2 =58%). An invasive approach was associated with a lower risk of recurrent myocardial infarction (RR, 0.76 [95% CI, 0.60–0.97]) and ischemia‐driven revascularization (RR, 0.29 [95% CI, 0.21–0.40]) without an increase in major bleeding (RR, 1.31 [95% CI, 0.86–1.97]) compared with a conservative approach. There were no significant differences between both approaches in cardiovascular mortality, acute cerebrovascular events, or length of hospital stay. Conclusions Among older adult patients with NSTEMI, there was no significant difference in survival between an invasive or a conservative approach. An invasive approach was associated with a lower risk of recurrent myocardial infarction and ischemia‐driven revascularization without an increase in the risk of major bleeding. The findings should help with informed decision‐making among older adult patients with NSTEMI.

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