Routine invasive vs. conservative strategy in elderly patients with non-ST-elevation acute coronary syndrome

Background: The optimal management of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) remains uncertain. This systematic review assessed invasive versus conservative strategies in this population. Methods: PubMed, Embase, and Scopus were searched through September 2024 for randomized controlled trials (RCTs) comparing both strategies. The primary outcome was major adverse cardiovascular events (MACE); secondary outcomes included all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, myocardial infarction, revascularization, stroke, and bleeding. Evidence certainty was evaluated using GRADE, and meta-analyses applied random-effects models. Results: Seven RCTs (n=2,997; mean age 81–86 years; 49% female) were included. Invasive management reduced MACE risk (HR 0.77, 95% CI 0.65–0.92), with consistent point estimate direction across trials. Myocardial infarction (HR 0.70, 95% CI 0.59–0.84) and revascularization (HR 0.45, 95% CI 0.23–0.90) were also significantly reduced. No significant differences were observed for all-cause mortality (HR 1.04, 95% CI 0.90–1.19), cardiovascular mortality (HR 1.10, 95% CI 0.86–1.41), stroke (HR 0.78, 95% CI 0.53–1.16), or bleeding (RR 1.23, 95% CI 0.90–1.69). Evidence certainty was moderate for most outcomes. Conclusion: In elderly NSTE-ACS patients, invasive management reduces cardiovascular events without significantly increasing bleeding, supporting individualized treatment decisions.