Early invasive versus conservative strategy in acute coronary syndrome in older adults: systematic review and meta-analysis

Acute coronary syndrome (ACS) disproportionately affects older adults, who face higher risks of mortality and complications due to frailty and comorbidities. Whether an early invasive strategy improves outcomes compared with conservative medical therapy in adults aged ≥65 years remains uncertain. Thus, we aimed to compare the efficacy and safety of early invasive therapy versus conservative medical management in older adults with ACS. We systematically searched PubMed, Embase, and Cochrane CENTRAL from inception to January 2026 for trials enrolling adults aged ≥65 years with ACS. The primary outcome was all-cause mortality, while secondary outcomes included recurrent myocardial infarction (MI), coronary revascularization, stroke, major bleeding, major adverse cardiovascular events (MACE), and major adverse cardiac and cerebrovascular events (MACCE). Risk ratios (RRs) were pooled using random-effects models, with heterogeneity assessed by the I² statistic. Additionally, cumulative meta-analyses were performed to examine trends over time. Eleven trials comprising 4251 patients were included. Most participants were aged >70 years, predominantly male, and primarily presented with non-ST-elevation myocardial infarction. Followup ranged from 6 months to 5 years. Early invasive therapy did not reduce all-cause mortality compared with conservative management (RR 1.04, 95% CI 0.98-1.10; p=0.19). However, it significantly reduced recurrent MI (RR 0.74, 95% CI 0.64-0.86; p<0.001) and coronary revascularization (RR 0.39, 95% CI 0.27-0.56; p<0.001). Major bleeding was increased with the invasive strategy (RR 1.67, 95% CI 1.08-2.59; p=0.02), while stroke rates were similar (RR 0.97, 95% CI 0.72-1.32; p=0.87). No significant differences were observed for MACE (RR 1.11, 95% CI 0.79-1.56; p=0.57) or MACCE (RR 0.92, 95% CI 0.65-1.29; p=0.62). Cumulative meta-analysis demonstrated stable effect estimates over time with no mortality benefit. In older adults with ACS, an early invasive strategy does not improve survival but reduces recurrent MI and subsequent revascularization while increasing major bleeding risk. These findings support individualized treatment decisions based on ischemic risk, bleeding risk, frailty, comorbidity burden, and patient preference rather than chronological age alone.