https://doi.org/10.1007/s00392-025-02625-4
1Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; 2Universitätsklinikum Schleswig-Holstein Lübeck, Deutschland; 3Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 4Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland; 5Universitätsklinikum Köln Klinik III für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; 6Klinikum Leverkusen Klinik für Akut- und Notfallmedizin Leverkusen, Deutschland; 7Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; 8Asklepios Westklinikum Rissen Abteilung für Kardiologie Hamburg, Deutschland
Background: Patients ≥80 years old were underrepresented or excluded from landmark trials demonstrating the superiority of primary percutaneous coronary intervention (PCI) as reperfusion strategy in ST-segment elevation myocardial infarction (STEMI). While recent evidence in older patients with non-ST-segment elevation myocardial infarction demonstrated that invasive management does not result in improved survival compared to conservative treatment, elderly with STEMI are usually referred for invasive strategy. These elderly have a high burden of frailty and comorbidities, conservative treatment might be a reasonable approach. There is a gap in the evidence regarding optimal management of STEMI in the elderly.
Objective: This meta-analysis assessed the effects of an invasive strategy with intended PCI compared to conservative treatment (CON) in the elderly (≥80 years) with STEMI.
Methods: A structured literature search was performed. The primary outcome was overall survival. Secondary outcome analyses included 30-day and 1-year mortality, major bleeding and heart failure hospitalizations. Random-effects meta-analyses were performed using the Mantel-Haenszel method for dichotomous event data. Pooled odds ratios (ORs) and 95% confidence intervals (CI) are given for each analysis with a two-sided significance level of p < 0.05.
Results: Thirteen studies reporting on 102158 elderly were included in the primary outcome analysis. Of these, 31629 (31%) were assigned to PCI and 70529 (69%) were managed conservatively. The overall survival was 76.5% in PCI and 67.2% in CON at the time of longest available follow-up (OR 2.18, 95% CI 1.79 to 2.66, p<0.001, I2 = 88%, favoring PCI). The follow-up period ranged from 30 days to 26.5 months.
The 30-day (OR 0.39, 95% CI 0.31 to 0.50, p<0.001, I2 = 0%) and 1-year mortality (OR 0.34, 95% CI 0.25 to 0.46, p<0.001, I2 = 0%,) were lower in PCI group. There was little to no difference in major bleeding (OR 1.55, 95% CI 0.77 to 3.12, p=0.22, I2 = 0%). Secondary heart failure hospitalizations were more frequent in PCI group (OR 1.17, 95% CI 1.11 to 1.23, p<0.001, I2 = 0%) with presumably underlying survivorship bias.
Conclusion: This meta-analysis indicates a potential underuse of PCI in the elderly with STEMI. As expected, PCI was advantageous in short- and long-term survival, but these results were affected by confounding. Nonetheless, every second patient in CON group was a long-term survivor. These findings are hypothesis generating, they indicate ageism and emphasize that PCI should not be automatically withheld in the elderly.
Moreover, the analysis highlights the demand for future randomized controlled trials assessing STEMI treatment strategies focusing on the elderly.