Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials
Abstract Background Advances in managing non-ST-elevation acute coronary syndrome (NSTE-ACS) have yet to clarify the optimal treatment for elderly patients, whose complex health profiles and underrepresentation in trials add challenges to decision-making. Methods We systematically searched PubMed, E...
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2025-02-01
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| Series: | BMC Cardiovascular Disorders |
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| Online Access: | https://doi.org/10.1186/s12872-025-04560-8 |
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| author | Erfan Kohansal Sepehr Jamalkhani Alireza Hosseinpour Fateme Yousefimoghaddam Amir Askarinejad Elnaz Hekmat Amir Ghaffari Jolfayi Armin Attar |
| author_facet | Erfan Kohansal Sepehr Jamalkhani Alireza Hosseinpour Fateme Yousefimoghaddam Amir Askarinejad Elnaz Hekmat Amir Ghaffari Jolfayi Armin Attar |
| author_sort | Erfan Kohansal |
| collection | DOAJ |
| description | Abstract Background Advances in managing non-ST-elevation acute coronary syndrome (NSTE-ACS) have yet to clarify the optimal treatment for elderly patients, whose complex health profiles and underrepresentation in trials add challenges to decision-making. Methods We systematically searched PubMed, Embase, Web of Science, and Scopus for randomized controlled trials comparing invasive versus conservative strategies in elderly patients (≥ 70 years) with NSTE-ACS through October 2024. Co-primary outcomes were all-cause and cardiovascular mortalities, with secondary outcomes including myocardial infarction (MI), revascularization, stroke, decompensated heart failure, and bleeding events. Outcomes were analyzed using both risk ratios (RR) and hazard ratios (HR). Results Analysis of 11 trials (4,114 patients) showed no significant differences in all-cause mortality (RR: 1.04, 95% CI: 0.98–1.11; HR: 1.10, 95% CI: 0.94–1.29) or cardiovascular mortality (RR: 0.98, 95% CI: 0.85–1.12; HR: 0.94, 95% CI: 0.73–1.20) between strategies. The invasive approach significantly reduced subsequent revascularization (RR: 0.41, 95% CI: 0.27–0.62; HR: 0.30, 95% CI: 0.19- 0.47; p < 0.01 in both analyses) and MI risk (RR: 0.75, 95% CI: 0.57–0.99, p = 0.04; HR: 0.64, 95% CI: 0.49–0.83, p < 0.01), though with some levels of heterogeneity in sensitivity analyses for MI. Stroke and heart failure outcomes were comparable between strategies. However, it significantly increased the risk of both composite major and minor bleeding risk (RR: 1.50, 95% CI: 1.02–2.20, p = 0.04) and major bleeding alone (RR: 1.92, 95% CI: 1.04–3.56, p = 0.04). Conclusion In elderly patients with NSTE-ACS, an invasive strategy reduces revascularization needs and, potentially, MI risk without impacting survival, but at the cost of increased bleeding risk. This supports individualized treatment decisions based on patient-specific characteristics, particularly bleeding risk and geriatric factors. |
| format | Article |
| id | doaj-art-29227f5de5f647b79a50853960845f4d |
| institution | DOAJ |
| issn | 1471-2261 |
| language | English |
| publishDate | 2025-02-01 |
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| series | BMC Cardiovascular Disorders |
| spelling | doaj-art-29227f5de5f647b79a50853960845f4d2025-08-20T02:48:16ZengBMCBMC Cardiovascular Disorders1471-22612025-02-0125111710.1186/s12872-025-04560-8Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trialsErfan Kohansal0Sepehr Jamalkhani1Alireza Hosseinpour2Fateme Yousefimoghaddam3Amir Askarinejad4Elnaz Hekmat5Amir Ghaffari Jolfayi6Armin Attar7Rajaie Cardiovascular Medical and Research Center, Iran University of Medical SciencesRajaie Cardiovascular Medical and Research Center, Iran University of Medical SciencesSchool of Medicine, Shiraz University of Medical SciencesRajaie Cardiovascular Medical and Research Center, Iran University of Medical SciencesRajaie Cardiovascular Medical and Research Center, Iran University of Medical SciencesMid and South Essex NHS Foundation TrustRajaie Cardiovascular Medical and Research Center, Iran University of Medical SciencesDepartment of Cardiovascular Medicine, School of Medicine, Shiraz University of Medical SciencesAbstract Background Advances in managing non-ST-elevation acute coronary syndrome (NSTE-ACS) have yet to clarify the optimal treatment for elderly patients, whose complex health profiles and underrepresentation in trials add challenges to decision-making. Methods We systematically searched PubMed, Embase, Web of Science, and Scopus for randomized controlled trials comparing invasive versus conservative strategies in elderly patients (≥ 70 years) with NSTE-ACS through October 2024. Co-primary outcomes were all-cause and cardiovascular mortalities, with secondary outcomes including myocardial infarction (MI), revascularization, stroke, decompensated heart failure, and bleeding events. Outcomes were analyzed using both risk ratios (RR) and hazard ratios (HR). Results Analysis of 11 trials (4,114 patients) showed no significant differences in all-cause mortality (RR: 1.04, 95% CI: 0.98–1.11; HR: 1.10, 95% CI: 0.94–1.29) or cardiovascular mortality (RR: 0.98, 95% CI: 0.85–1.12; HR: 0.94, 95% CI: 0.73–1.20) between strategies. The invasive approach significantly reduced subsequent revascularization (RR: 0.41, 95% CI: 0.27–0.62; HR: 0.30, 95% CI: 0.19- 0.47; p < 0.01 in both analyses) and MI risk (RR: 0.75, 95% CI: 0.57–0.99, p = 0.04; HR: 0.64, 95% CI: 0.49–0.83, p < 0.01), though with some levels of heterogeneity in sensitivity analyses for MI. Stroke and heart failure outcomes were comparable between strategies. However, it significantly increased the risk of both composite major and minor bleeding risk (RR: 1.50, 95% CI: 1.02–2.20, p = 0.04) and major bleeding alone (RR: 1.92, 95% CI: 1.04–3.56, p = 0.04). Conclusion In elderly patients with NSTE-ACS, an invasive strategy reduces revascularization needs and, potentially, MI risk without impacting survival, but at the cost of increased bleeding risk. This supports individualized treatment decisions based on patient-specific characteristics, particularly bleeding risk and geriatric factors.https://doi.org/10.1186/s12872-025-04560-8ElderlyNon-ST-Elevation Acute Coronary SyndromeInvasive StrategyConservative ManagementMeta-analysis |
| spellingShingle | Erfan Kohansal Sepehr Jamalkhani Alireza Hosseinpour Fateme Yousefimoghaddam Amir Askarinejad Elnaz Hekmat Amir Ghaffari Jolfayi Armin Attar Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials BMC Cardiovascular Disorders Elderly Non-ST-Elevation Acute Coronary Syndrome Invasive Strategy Conservative Management Meta-analysis |
| title | Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials |
| title_full | Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials |
| title_fullStr | Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials |
| title_full_unstemmed | Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials |
| title_short | Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials |
| title_sort | invasive versus conservative strategies for non st elevation acute coronary syndrome in the elderly an updated systematic review and meta analysis of randomized controlled trials |
| topic | Elderly Non-ST-Elevation Acute Coronary Syndrome Invasive Strategy Conservative Management Meta-analysis |
| url | https://doi.org/10.1186/s12872-025-04560-8 |
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