A routine invasive approach should not be replaced with a more selective strategy for older patients with NSTEMI—the most common type of heart attack—according to results from the EVAOLD trial presented at ESC Congress 2026. The trial compared stress imaging-guided selective invasive management with standard routine invasive management in patients ages 80 and older.
Myocardial infarction without ST segment elevation is typically treated with an invasive strategy involving angiography, where coronary artery blood flow is visualized using contrast dye and blocked arteries are reopened as needed. The benefit-risk balance of this approach in older patients has been uncertain due to increased complications and lack of randomized trial evidence, according to principal investigator Professor Gilles Barone-Rochette from University Hospital of Grenoble, La Tronche, France.
The open-label noninferiority trial randomized 587 of a planned 1,756 patients across 25 French centers. One group received stress testing followed by angiography only for moderate-severe disease; the other received angiography for all patients without prior stress testing. The primary endpoint—death from any cause, nonfatal myocardial infarction, or nonfatal stroke at one year—occurred in 24.1% of the imaging-guided selective strategy group and 20.7% of the routine invasive group.
The trial was stopped early for futility at the interim analysis. Although the stress imaging-guided selective strategy reduced the need for coronary angiography and related complications, it did not demonstrate noninferiority to routine invasive management, Barone-Rochette noted. He added that implementing the stress imaging-guided strategy proved challenging in this population.
