Beyond Chronological Age: Balancing Risk and Benefit of Invasive Versus Conservative Strategies in Acute Coronary Syndrome Patients Aged ≥75 Years. A Systematic Review and Meta-Analysis

Abstract

Acute coronary syndrome (ACS) in patients aged ≥75 years presents a clinical challenge because of frailty, comorbidities, and increased procedural risks. This systematic review and meta-analysis evaluated the benefits and risks of invasive compared with conservative strategies in elderly patients with ACS. A systematic search was conducted in PubMed and the Cochrane Library for randomized controlled trials published between 2016 and 2026. Six studies involving more than 4,000 patients were included. The pooled analysis showed no statistically significant overall difference between invasive and conservative strategies (Hedges’ g = −1.04; 95% CI: −3.12 to 1.04), with substantial heterogeneity among studies (I² = 99%). Invasive treatment showed a trend toward reducing nonfatal myocardial infarction and repeat revascularization, although potential procedural complications remained important considerations. These findings suggest that invasive strategies do not consistently provide superior overall outcomes in elderly patients with ACS. Treatment decisions should therefore consider not only chronological age but also frailty, comorbidities, functional status, life expectancy, and patient preferences.