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

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]; I2=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, I2=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.