A\u00a0routine\u00a0invasive approach should not be replaced with a more selective approach in older patients with the most common type of heart attack.\u00a0This was the main finding of the EVAOLD trial\u00a0presented in\u00a0a Hot Line session today at ESC Congress 2026.<\/p>\n
Myocardial infarction without ST segment elevation (NSTEMI) is\u00a0the most\u00a0common\u00a0type\u00a0of\u00a0heart attack.\u00a0It is\u00a0generally recommended\u00a0that NSTEMI is treated\u00a0using\u00a0an\u00a0invasive strategy involving\u00a0angiography\u00a0\u2013\u00a0where\u00a0coronary artery\u00a0blood flow\u00a0is visualized\u00a0using contrast dye injected\u00a0through a\u00a0catheter\u00a0\u2013\u00a0with\u00a0reopening of\u00a0blocked arteries\u00a0where needed.\u00a0<\/p>\n
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The benefit\u2013risk balance of routine invasive management remains uncertain in older patients\u00a0due to the increased risk of complications\u00a0and the lack of evidence of its benefit from randomized trials. We hypothesized that stress testing may act as a gatekeeper, helping to select\u00a0the\u00a0older patients\u00a0who\u00a0would\u00a0most likely\u00a0benefit from an invasive strategy.”\u00a0<\/p>\n
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Professor Gilles Barone-Rochette, Principal Investigator of the EVAOLD trial, University Hospital of Grenoble, La Tronche, France<\/p>\n
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Stress testing\u00a0provides\u00a0a non-invasive way to assess\u00a0the\u00a0extent that\u00a0blood flow is reduced\u00a0to the heart (myocardial ischaemia). It involves the administration of a drug that makes the heart work harder, for\u00a0a 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.\u00a0<\/p>\n
This\u00a0open-label\u00a0noninferiority trial was conducted at 25 French centres. Patients\u00a0aged\u00a080 years or older\u00a0who were hospitalized\u00a0with NSTEMI were\u00a0included. They were\u00a0randomized to receive\u00a0either\u00a0stress imaging-guided selective invasive management\u00a0(a stress test then angiography only for moderate\u2013severe disease)\u00a0or routine invasive management\u00a0(angiography for all, without stress testing).\u00a0<\/p>\n
At the first prespecified interim analysis, after 587 of the planned 1,756 patients had been randomized,\u00a0the trial was stopped for futility because the conditional power to demonstrate noninferiority was low.\u00a0The primary endpoint was death from any cause, nonfatal myocardial\u00a0infarction\u00a0or nonfatal stroke at\u00a0one\u00a0year. 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%\u00a0confidence interval\u00a00.86 to 1.72; p=0.27).\u00a0<\/p>\n
“Although the stress imaging-guided selective strategy reduced\u00a0the need for coronary angiography and angiography-related complications, it did not demonstrate noninferiority to routine invasive management for major cardiovascular events,”\u00a0commented\u00a0Professor Barone-Rochette.\u00a0He\u00a0noted\u00a0that the results\u00a0should be interpreted in the context of early termination and lower-than-anticipated event rates.\u00a0“The trial also showed that implementing the stress imaging-guided strategy was challenging in this population, which is an important finding in itself,”\u00a0concluded Professor Barone-Rochette.\u00a0<\/p>\n
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