Routine Invasive Heart Attack Treatment Still Best for Very Elderly Patients, EVAOLD Trial Finds

A large clinical trial in France, called EVAOLD, has found that doctors should not replace the standard invasive approach to treating heart attacks in very elderly patients with a more selective, test-guided strategy. The results were presented in a Hot Line session at the ESC Congress 2026.

NSTEMI (myocardial infarction without ST-segment elevation), the most common type of heart attack, is generally treated with an invasive strategy: angiography, in which a catheter and contrast dye are used to visualize blood flow in the coronary arteries, followed by reopening 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," said principal investigator Professor Gilles Barone-Rochette of University Hospital of Grenoble, La Tronche, France. His team hypothesized that a noninvasive stress test could act as a gatekeeper to identify which older patients would benefit most from the invasive approach. Stress testing assesses reduced blood flow to the heart by giving a drug that makes the heart work harder briefly, while it is imaged using echocardiography or single-photon emission computed tomography (SPECT).

The open-label, noninferiority EVAOLD trial, conducted at 25 French centers, enrolled patients aged 80 and older who were hospitalized with NSTEMI. They were randomly assigned to either stress imaging-guided selective invasive management, a stress test followed by angiography only for those with moderate-to-severe disease, or routine invasive management, angiography for everyone without stress testing.

At a planned interim analysis, after 587 of a planned 1,756 patients had been enrolled, the trial was stopped for futility because the chance of proving noninferiority was low. The primary endpoint, death from any cause, nonfatal heart attack or nonfatal stroke at one year, occurred in 24.1% of patients in the stress-imaging-guided group compared with 20.7% in the routine invasive group.

While the selective strategy reduced the need for angiography and its related complications, it did not demonstrate noninferiority to routine invasive management for these major cardiovascular events, Professor Barone-Rochette said, adding that the results should be read in the context of the trial's early termination and lower-than-expected event rates. He also noted that implementing the stress imaging-guided strategy proved challenging in this patient population, calling it "an important finding in itself."