Older heart attack patients need routine invasive treatment rather than selective care

A routine invasive approach should not be replaced with a more selective approach in older patients with the most common type of heart attack. This was the main finding of the EVAOLD trial presented in a Hot Line session today at ESC Congress 2026.

Myocardial infarction without ST segment elevation (NSTEMI) is the most common type of heart attack. It is generally recommended that NSTEMI is treated using an invasive strategy involving angiography – where coronary artery blood flow is visualized using contrast dye injected through a catheter – with reopening of blocked arteries where needed. 

The benefit–risk balance of routine invasive management remains uncertain in older patients due to the increased risk of complications and the lack of evidence of its benefit from randomized trials. We hypothesized that stress testing may act as a gatekeeper, helping to select the older patients who would most likely benefit from an invasive strategy." 

Professor Gilles Barone-Rochette, Principal Investigator of the EVAOLD trial, University Hospital of Grenoble, La Tronche, France

Stress testing provides a non-invasive way to assess the extent that blood flow is reduced to the heart (myocardial ischaemia). It involves the administration of a drug that makes the heart work harder, for a short time, while the heart is imaged using echocardiography or single-photon emission computed tomography (SPECT). The EVAOLD trial compared stress imaging-guided selective invasive management with routine invasive management. 

This open-label noninferiority trial was conducted at 25 French centres. Patients aged 80 years or older who were hospitalized with NSTEMI were included. They were randomized to receive either stress imaging-guided selective invasive management (a stress test then angiography only for moderate–severe disease) or routine invasive management (angiography for all, without stress testing). 

At the first prespecified interim analysis, after 587 of the planned 1,756 patients had been randomized, the trial was stopped for futility because the conditional power to demonstrate noninferiority was low. The primary endpoint was death from any cause, nonfatal myocardial infarction or nonfatal stroke at one year. The primary endpoint occurred in 24.1% of patients in the imaging-guided selective strategy group and in 20.7% of patients in the routine invasive group (hazard ratio 1.22; 95% confidence interval 0.86 to 1.72; p=0.27). 

"Although the stress imaging-guided selective strategy reduced the need for coronary angiography and angiography-related complications, it did not demonstrate noninferiority to routine invasive management for major cardiovascular events," commented Professor Barone-Rochette. He noted that the results should be interpreted in the context of early termination and lower-than-anticipated event rates. "The trial also showed that implementing the stress imaging-guided strategy was challenging in this population, which is an important finding in itself," concluded Professor Barone-Rochette.