Routine Invasive Approach Preferred for Older NSTEMI Patients: EVAOLD Trial Findings

The EVAOLD Trial Findings on NSTEMI Treatment in Patients Aged 80 and Older

Myocardial infarction without ST segment elevation, commonly known as NSTEMI, represents the most frequent form of heart attack. Standard medical guidelines generally recommend treating NSTEMI with an invasive strategy involving coronary angiography, where clinicians visualize blood flow using contrast dye injected via a catheter and reopen blocked arteries when necessary. However, the risk-benefit balance for routine invasive management in older adults has remained uncertain due to elevated complication risks and a lack of randomized trial evidence specifically supporting this age group, according to Professor Gilles Barone-Rochette, the trial’s principal investigator from University Hospital of Grenoble in La Tronche, France, as reported by the European Society of Cardiology. To investigate whether physicians could safely spare older patients unnecessary procedures, researchers designed the EVAOLD trial to test a selective approach. Investigators hypothesized that non-invasive stress testing could serve as a gatekeeper to identify patients who would genuinely benefit from subsequent angiography. The open-label noninferiority trial spanned 25 French centers and enrolled patients aged 80 or older who were hospitalized with NSTEMI. Participants were randomized into two distinct groups: one receiving stress imaging-guided selective invasive management—incorporating a stress test followed by angiography only if moderate-to-severe disease was detected—and another receiving routine invasive management involving angiography for all patients without prior stress testing.

Trial Stoppage and Outcome Metrics

The trial was terminated early during its first prespecified interim analysis after 587 of the planned 1,756 patients had undergone randomization. According to data released by the European Society of Cardiology, the trial was stopped for futility because the conditional power required to demonstrate noninferiority was too low. When evaluating the primary endpoint—a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke at the one-year mark—researchers observed events in 24.1% of patients assigned to the imaging-guided selective strategy group. In comparison, the routine invasive group experienced primary endpoint events in 20.7% of patients, yielding a hazard ratio of 1.22 with a 95% confidence interval ranging from 0.86 to 1.72 and a p-value of 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.

Professor Gilles Barone-Rochette, University Hospital of Grenoble Professor Barone-Rochette noted that these results require careful interpretation given the early termination of the trial and lower-than-anticipated event rates overall. He added that implementing the stress imaging-guided strategy proved challenging within this specific patient demographic, which stands as a significant clinical insight in its own right. Consequently, investigators concluded that the tested selective approach should not replace routine invasive treatment whenever an invasive strategy remains clinically feasible for older NSTEMI patients.