Background:  

With increasing life expectancy, the proportion of elderly patients with NSTE-ACS is continuously growing. Since evidence from randomized clinical studies is limited in this patient population, two different approaches have been evolved over the last years: The first strategy consists an early invasive management strategy. Furthermore, an initial conservative therapeutic strategy including optimal medical therapy and limited selective invasive therapy in case of persistent myocardial ischemia is being performed. The aim of this entire systemic review is to assess whether an invasive or a conservative management strategy in elderly patients with NSTE-ACS impacts their intra-hospital and one-year follow-up outcome.

Methods and results: 

We searched the following databases up to 11 April 2020: PubMed, EMBASE, Google Scholar and the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, with no language restrictions and selected publications as follows: Prospective randomized controlled trials (RCT) as well as observational registries (OBR) that enrolled NSTE-ACS patients ≥ 75 years with comparative outcome reporting of invasive and conservative strategy were investigated. Two review authors independently screened the records, extracted data and assessed the quality of included studies. The primary outcomes were all-cause mortality, re-infarction and the prevalence of stroke as well as bleeding rates during the index hospitalization. The secondary outcome assessed all-cause mortality after one year.

15 studies consisting five RCTs with a total of 1526 participants (765 invasive strategies, 761 conservative strategies) and ten OBR with a total of 1010062 participants (173611 invasive strategies, 836451 conservative strategies) were included. There was an overall survival benefit intra-hospital as well as after one year for patients undergoing invasive as compared to the conservative management strategy: The overall Odds Ratio (OR) for intra-hospital all-cause mortality was 0.45 (95% CI 0.34 to 0.59, p<0.00001), for intra-hospital bleeding 1.32 (95% CI 0.71 to 2.43, p<0.00001) and finally for intra-hospital re-infarction 1.00 (95% CI 0.49 to 2.05, P<0.00001) in favor of an invasive strategy. For incidental intra-hospital stroke no relevant difference was assessable (OR=0.51;95% CI 0.49 to 0.53, p=0.81) among the treatment strategies. Moreover, most important, similar effect was observed for all-cause mortality at one year (OR=0.42, 95% CI 0.32 to 0.56, p<0.00001). However, this effect was inconsistent, when comparing the mortality results at 1-year referred calculated from RCTs OR=0.97; 95% CI 0.71 to 1.32, p=0.74) to those from registries (OR=0.29; 95% CI 0.22 to 0.39, p<0.00001). This may be explained by a significant selection bias, where mostly healthier and fitter patient underwent invasive strategy than multi-morbid patients with predominant conservative medical therapy.

Conclusions  

This meta-analysis strengthens evidence for an invasive management strategy as compared to conservative management strategy in aged patients with NSTE-ACS in favor of reduced all-cause mortality over one year. Furthermore, the risk for re-infarction was significantly reduced choosing by an early invasive approach. Further prospective randomized controlled trials are necessary to establish a proper evidence–based recommendation concerning the optimal treatment strategy of NSTE-ACS in the elderly.