Evaluation of a Strategy Guided by Imaging Versus Systematic Coronary Angiography in Elderly Patients With Ischemia: a Multicentric Randomized Non Inferiority Trial (EVAOLD)

EVAOLD

Patient / Population Intervention / Exposition Comparaison Critère de jugement

In 587 patients aged 80 years or over with NSTEMI, a selective invasive strategy guided by stress imaging was not non-inferior to routine invasive management for death, myocardial infarction or stroke at 12 months.

N

587patients

Schéma

Multicentre (France), open-label, 1:1 randomised, two-arm parallel non-inferiority trial; 12-month follow-up; non-inferiority declared if the upper limit of the one-sided 97.5% CI for the hazard ratio is <1.24 (7% absolute margin); registry status "terminated" after a planned interim analysis

Critère

MACCE (all-cause death, non-fatal myocardial infarction, non-fatal stroke) at 12 months

Pertinence

2Important — l’un des piliers parmi d’autres.

RésultatRecruitment stopped for futility after 587 of the planned 1,756 patients. Death, myocardial infarction or stroke at one year occurred in 24.1% with the selective strategy and 20.7% with routine invasive management (HR 1.22, 95% CI 0.86–1.72; P = 0.27), so non-inferiority was not shown. The selective strategy did reduce the number of angiograms and their attendant complications.

Barone-Rochette G, et al. Presented at ESC Congress 2026, Hot Line 11, 31 August.

Discussion et critique

Sparing the very old an angiogram is an attractive idea and this trial could not show it is safe: the point estimate ran the wrong way, the confidence interval reached 1.72, and the data monitors stopped enrolment at a third of target for futility. That is not proof of harm — 587 patients and 130-odd events leave room for a smaller difference either way — but it removes the argument that stress imaging first is a defensible default at 80 and over. What the strategy did buy is fewer catheterisations; whoever wants to trade procedures for a possible excess of events now has to say so explicitly.