Efficacy And Safety of Early Invasive Vs Conservative Strategies for Non–St-Elevation Acute Coronary Syndromes in Older Patients: An Updated Systematic Review

Abstract

Background: Cardiovascular disease remains the leading cause of morbidity and mortality worldwide, with non–ST-segment elevation acute coronary syndrome (NSTE-ACS) representing a common presentation in older adults. Management of this population is challenging due to the balance between reducing ischemic risk and minimizing bleeding, frailty-related complications, and comorbidities. This systematic review aimed to compare the efficacy and safety of early invasive versus conservative strategies in elderly patients with NSTE-ACS.

Methodology: A systematic search of PubMed, Scopus, Web of Science, and Google Scholar was conducted for studies published between 2015 and 2025, following PRISMA guidelines. Eligible studies included patients aged ≥65 years with NSTE-ACS who received either invasive or conservative treatment. Eleven studies (five randomized controlled trials, three systematic reviews, and three prospective observational studies) comprising over 350,000 patients were included. Data extraction covered mortality, major adverse cardiovascular events (MACE), myocardial infarction, revascularization rates, bleeding outcomes, and quality-of-life measures. Risk of bias was assessed using the Cochrane Collaboration tool.

Results: This review included 11 studies (5 RCTs, 3 systematic reviews, and 3 prospective observational studies) involving over 350,000 elderly patients (mean age 69–86 years). Invasive strategies were consistently associated with reduced MACE, recurrent myocardial infarction, and unplanned revascularization compared with conservative therapy. Mortality benefits were observed in pooled analyses but remained inconsistent across individual RCTs, particularly in very elderly or frail patients. Event-free survival was longer, and early angina relief more common with invasive treatment, though differences diminished over time. A trade-off was evident, with invasive therapy carrying a two- to three-fold higher risk of major bleeding. Overall, invasive management provided significant ischemic and functional benefits, though its advantages were attenuated in patients with advanced age, frailty, or prior coronary interventions.

Conclusion: Early invasive strategies offer significant ischemic and functional benefits in elderly patients with NSTE-ACS, though increased bleeding risk and variable mortality outcomes necessitate individualized decision-making. Frailty and comorbidities should guide therapeutic choices to optimize outcomes.