Older women with non-ST-elevation acute coronary syndrome undergoing invasive or conservative management: an individual patient data meta-analysis

Women and older patients are underrepresented in randomized controlled trials (RCTs) investigating treatment strategies following acute coronary syndrome. This study aims to evaluate the benefit of invasive vs. conservative strategy of older women with non-ST-elevation acute coronary syndrome (NSTEACS). This analysis from an individual patient data meta-analysis included six RCTs comparing an invasive management with a conservative management in older NSTEACS patients. The primary endpoint was the composite of all-cause mortality or myocardial infarction (MI). Secondary endpoints included all-cause mortality, cardiovascular death, MI, urgent revascularization, and stroke. Follow-up time was censored at 1 year. In total, 717 women [median age 84.0 (interquartile range 81.0-87.0) years] were included. The primary endpoint occurred in 21.0% in the invasive strategy vs. 27.8% in the conservative strategy [hazard ratio (HR) 0.77, 95% confidence interval (CI) 0.52-1.13, = 0.160 using random effect] at 1-year follow-up. The invasive management was associated with reduced risk of MI (HR 0.49, 95% CI 0.32-0.73, < 0.001) and urgent revascularization (HR 0.44, 95% CI 0.20-0.98, = 0.045). No significant differences were identified in the risk of all-cause mortality, cardiovascular death, and stroke. Among males, there was no significant association between the treatment strategy and primary or secondary endpoints. An invasive strategy compared with a conservative strategy did not reduce the composite outcome of all-cause mortality or MI in older NSTEACS women at 1-year follow-up. An invasive strategy reduced the individual risk of MI and urgent revascularization. Our results support the beneficial role of the invasive strategy in older NSTEACS women. This meta-analysis is registered with PROSPERO (CRD42023379819).