NSTEMI in the oldest-old: prognosis and impact of invasive management in patients ≥ 85 years

INTRODUCTION: As the population ages, non–ST-segment elevation myocardial infarction (NSTEMI) in the oldest-old poses unique management challenges, yet this group remains underrepresented in clinical trials. Hence, the present study sought to evaluate clinical outcomes and the effectiveness of coronary intervention in patients aged ≥ 85 years with NSTEMI admitted to the intensive coronary care unit (ICCU) of a tertiary center within an unselected, contemporary cohort. METHODS: All consecutive patients aged ≥ 60 years admitted to the ICCU with a diagnosis of NSTEMI between July 2019 and June 2024 were included. Patients were stratified into two groups according to age (60–84 years and ≥ 85 years). The primary outcome was all-cause mortality at 45 days, 6 months, and long-term follow-up. Multivariable Cox proportional hazards models were used to identify independent predictors of mortality. To address potential confounding by indication, propensity scores for receiving percutaneous coronary intervention (PCI) were estimated, and inverse probability of treatment weighting (IPTW) was applied within each age group. RESULTS: A total of 967 patients were enrolled, with a mean age of 73.6 ± 8.9 years; 137 (14%) were aged ≥ 85 years. Invasive management, including percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), was more common in the younger cohort (75.1% vs. 63.5%, p < 0.05), while the rates of diagnostic angiography without intervention were similar between groups (18.3% vs. 19.2%, p = 0.85). Mortality was significantly higher among older patients at all time points: 45 days (14.6% vs. 5.9%, p < 0.001), 6 months (19.7% vs. 8.5%, p < 0.001), and beyond 6 months (42.3% vs. 17.9%, p < 0.001). In multivariable Cox analysis, revascularization was independently associated with lower mortality (HR 0.565; 95% CI 0.38–0.84; p = 0.002). Propensity score–adjusted analyses yielded consistent results, demonstrating lower mortality among patients undergoing revascularization, particularly in the 60–84 year group, with similar directional trends observed in patients aged ≥ 85 years. CONCLUSIONS: Patients ≥ 85 years with NSTEMI had higher mortality than younger patients. In this real-world cohort, invasive management was associated with improved survival, including among carefully selected very elderly patients. These findings support an individualized approach to treatment selection rather than exclusion based only on chronological age.