Invasive vs. conservative management in nonagenarians with acute coronary syndrome: a systematic review and meta-analysis
P K Vlachakis, P Theofilis, S Aghayan, A Apostolos, N Ktenopoulos, I Kachrimanidis, E Mantzouranis, P Karakasis, G Zorbas, S Tsalamandris, A Synetos, M Drakopoulou, K Tsioufis, D Tousoulis, K ToutouzasAbstract
Background
Nonagenarians with acute coronary syndrome (ACS) are frequently underrepresented in clinical trials, leading to uncertainty regarding the optimal management strategy. While invasive management is guideline-recommended for ACS, concerns regarding frailty, comorbidities, and procedural risk often lead to a conservative approach in this very elderly population.
Purpose
To evaluate the impact of an invasive strategy compared with a conservative strategy on in-hospital and long-term mortality among nonagenarians presenting with ACS.
Methods
A systematic review and meta-analysis were conducted in 3 databases (Pubmed, Scopus, Web of Science) assessing studies that compared an invasive strategy that included percutaneous coronary intervention versus conservative management in patients aged ≥90 years with ACS. The primary outcomes were in-hospital mortality and long-term mortality. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Statistical heterogeneity was assessed using the I² statistic.
Results
Database search yielded 1289 studies. After removal of duplicates and title/abstract screening, the full text of 74 manuscripts was assessed. Ultimately, 12 studies were included for data extraction. Nine studies comprising 1,902 nonagenarians (881 invasive, 1,021 conservative) were assessed in-hospital mortality. An invasive strategy was associated with a significant reduction in in-hospital mortality compared with conservative management (RR 0.57, 95% CI 0.43–0.75; p = 0.0016), with considerable heterogeneity (I² = 73.9%). Ten studies including 1,138,508 patients (98,829 invasive, 1,039,679 conservative) contributed to the long-term mortality analysis. Invasive management was associated with significantly lower long-term mortality (RR 0.62, 95% CI 0.49–0.77; p = 0.0009), with substantial between-study heterogeneity (I² = 93.8%).
Conclusion
Among nonagenarians with ACS, an invasive strategy is associated with significantly lower in-hospital and long-term mortality compared with conservative management. Despite substantial heterogeneity, these findings suggest that advanced age alone should not preclude consideration of invasive management in carefully selected nonagenarian patients.In-Hospital Mortality in NonagenariansFor image description, please refer to the figure legend and surrounding text.Long-Term Mortality in NonagenariansFor image description, please refer to the figure legend and surrounding text.