Background: Current guidelines recommend that patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) at high risk undergo an early invasive coronary angiography after admission within 24 hours. However, elderly patients are under-represented in randomized trials and in “real world” practice fear of complications related to the procedure and uncertainty of benefit in elderly patients are common reasons for invasive procedures being withheld.
Purpose: To perform a comprehensive analysis of invasive versus conservative treatment in elderly patients with NSTE-ACS based on present evidence.
Methods: We searched Pubmed and Embase from inception until October 1, 2015 for studies that enrolled individuals older than 75 years with NSTE-ACS and allocated patients to either an invasive or conservative strategy. Search term was as follows: (“acute coronary syndrome” OR “non-ST-elevation myocardial infarction” OR “unstable angina”) AND (“invasive” OR “conservative” OR “angiography”) AND (“elderly” OR “older age”).
Results: Fourteen eligible studies (3 randomized controlled trials and 11 observational studies) were finally included in this meta-analysis, enrolling a total of 1034596 elderly NSTE-ACS patients recruited in the span of 1996 to 2010 years. Quantitative analysis showed that an invasive coronary angiography does significantly reduce the risk of death in comparison with conservative treatment (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.31 to 0.54, P<0.00001); the definite benefit was mainly observed in observational studies (OR 0.36, 95% CI 0.26 to 0.48, P<0.00001), and the risk of death also showed a strong trend toward reduction with invasive strategy (OR 0.81, 95% CI 0.61 to 1.09, P=0.17) in randomized controlled trials. For the outcome of bleeding complications reported in 9 studies, there was a little higher risk of occurring in-hospital major bleeding events (OR 1.54, 95% CI 0.71 to 3.30, P=0.27; reported in 7 studies) or any bleeding events (OR 1.45, 95% CI 0.72 to 2.90, P=0.30) in patients treated with invasive strategy than those treated with conservative strategy. However, the difference was not statistically significant.
Conclusion: Our analysis of this large population of elderly patients with NSTE-ACS demonstrated that an invasive treatment strategy was associated with lower mortality in comparison with a conservative approach without significantly increasing the risk of bleeding complications.