Balancing the benefit/risk of harm is crucial in elderly patients with ACS because they have higher risk of mortality but, also, higher risk of bleeding or other side effects of currently recommended treatments. Compared to younger patients, older patients are admitted more frequently with NSTEMI and medical treatments or revascularization are commonly underused
[25,26][25][26]. Current NSTEMI guidelines clearly state that interventional procedures for revascularization should be applied at any age
[13]. Nonetheless, age is frequently reported as the variable most closely related to lower revascularization rates
[27]. Of all the reasons postulated for the underuse of revascularization, the leading limitations might be the excess of bleeding complications or the lack of long-term benefit
[28]. Bleeding complications have certainly increased in recent decades due to the incorporation of more potent antiplatelet and anticoagulant strategies
[29]. In contrast, vascular access complications have decreased substantially with the generalization of radial access, especially in the elderly and high-bleeding risk patients
[30,31][30][31]. The largest clinical trial involving elderly patients with NSTEMI, or unstable angina, was the After Eighty study that included 457 patients who were randomized to either an invasive or conservative treatment strategy
[32]. After 1.5 years of follow-up, the invasive strategy was superior to a conservative strategy in reducing the primary endpoint, namely, a composite of myocardial infarction, urgent revascularization, stroke, or death. The primary endpoint was reduced by 47% using the invasive strategy (hazard ratio 0.53, 95% CI 0.41–0.69;
p = 0.0001), although the benefit was lower in patients aged >85, and no differences in terms of bleeding complications were noted. It should be noted that in this trial, a strict conservative strategy was applied instead of a selective invasive strategy, with no coronary angiography performed in any patient assigned to this group. In 2020, the SENIOR-NSTEMI study was published, which was an observational study with 1976 NSTEMI patients aged >80
[33]. After propensity score matching, it showed that revascularization within the first 3 days of admission was associated to 32% reduction in all-cause mortality (hazard ratio: 0.68, 95% CI 0.55–0.84). This study had several limitations because it did not assess the effect of heart failure of index hospitalization on post-discharge prognosis, and heart failure incidence was not assessed taking all-cause mortality as a competing event
[34,35][34][35].
Lastly, revascularization procedures could also be discussed. The use of drug-eluting stents has been generalized in percutaneous revascularization, and several trials have demonstrated their superiority compared to bare-metal stents also in the elderly
[36]. Polymer-free drug-eluting stents have demonstrated to have a very low risk of stent thrombosis with short-term dual antiplatelet treatments
[37], and this has also been demonstrated in second and third generations of drug-eluting stents
[38]. Another important aspect is the relevance of the complete revascularization in this age group. Agra-Bermejo et al. observed in a propensity-score analysis of an observational cohort a long-term benefit in terms of mortality of complete vs. culprit-only revascularization in older patients with NSTEMI
[39]. However, other studies showed controversial results
[40,41][40][41]. Further randomized evidence is warranted to clarify the better strategy regarding complete revascularization in the older patient.
In conclusion, an invasive strategy with currently available technologies (radial access and newer generation drug-eluting stents) is safe and effective to improve outcomes in elderly patients with NSTEMI and, therefore, it should not be denied in this patient group.