Invasive treatment strategy for older patients with non-ST-elevation acute coronary syndrome: a systematic review and meta-analysis of randomized controlled trials

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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 vs. 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 (3,887 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. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024629566, PROSPERO CRD42024629566.

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