28 September 2026
Press
- Journée nationale
Fewer invasive tests, fewer complications: for patients aged 80 and older who have suffered a heart attack, stress imaging could transform their care. The results of the EVAOLD clinical trial, sponsored by the Grenoble Alpes University Hospital and coordinated by Prof. Gilles Barone-Rochette, show that a strategy based on this new approach could significantly reduce the need for coronary angiography and revascularization, although non-inferiority has not been demonstrated. Presented at the 2026 European Society of Cardiology (ESC) Congress in Munich, these results are the product of work by teams from the French clinical research network FACT—designated F-CRIN—which specializes in coronary artery disease and atherothrombosis.
After age 80, how can we limit the use of invasive procedures?
For patients aged 80 and older, the management of a myocardial infarction is particularly challenging: frailty, comorbidities, or impaired renal function can increase the risks associated with medical procedures. For this type of heart attack, the current recommended strategy involves performing a coronary angiography, an invasive procedure that visualizes the heart’s arteries to identify narrowing or blockages. This may lead to revascularization, typically through angioplasty with stent placement. However, these procedures carry risks, particularly in very elderly patients.
It is in this context that EVAOLD, a national, prospective, randomized, and multicenter clinical trial was launched by the Grenoble Alpes University Hospital to evaluate an alternative approach: using stress imaging to select patients requiring a coronary angiography, rather than routinely performing this procedure. EVAOLD focused on patients who had suffered a myocardial infarction known as “non-ST-segment elevation,” a common type of heart attack that does not show the characteristic sign on an electrocardiogram seen in other types of heart attacks.
Patient enrollment for this trial, funded under a Hospital Clinical Research Program (PHRC) of the Ministry of Health, was conducted by teams from the FACT/F-CRIN network at 25 French centers.
What is stress imaging?
Stress imaging is a test that evaluates how the heart functions when it is under increased stress, either through physical exertion or the use of medication. It helps identify areas of the heart muscle that are not receiving enough blood and oxygen. This may involve a myocardial scintigraphy or a stress echocardiogram; both methods were used in the EVAOLD study to determine which patients should undergo coronary angiography.
A significant reduction in coronary angiograms: 31.9% of patients underwent stress imaging, compared with 99% under the systematic invasive strategy.
The analysis included 572 patients aged 80 and older, with a mean age of 85.7 years, of whom 52.6% were women. Patients were randomly assigned to two groups: in the first, stress imaging guided the decision on whether to perform a coronary angiography; in the second, patients received the routine invasive strategy, with a coronary angiography performed within 72 hours of diagnosis.
The results show a significant reduction in the use of invasive procedures with the imaging-guided strategy. With stress imaging, only 1 in 3 patients underwent coronary angiography (31.9%, compared to 99% with the systematic invasive strategy).Complications related to these procedures were more than four times less frequent : 2.1% versus 9.3%. This result is particularly noteworthy in a population with a mean age of nearly 86 years. Finally, fewer patients required revascularization: 22.3% versus 55.5%.
Fewer invasive procedures, but caution is still needed
EVAOLD was also designed to determine whether this significant reduction in the number of coronary angiograms could be achieved without increasing the risk of death, recurrent myocardial infarction, or stroke at one year. These events occurred in 24.1% of patients undergoing stress imaging, compared with 20.7% of those undergoing a routine invasive strategy. The non-inferiority of the imaging-guided strategy was not demonstrated: HR 1.22 (95% CI 0.86–1.72), with a non-inferiority margin set at 1.24; the upper limit of the confidence interval thus exceeded this threshold. Thus, in elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI), when the invasive strategy is clinically feasible, coronary angiography should not be replaced by a strategy using stress imaging as a “gatekeeper.”
“EVAOLD addresses a very specific question: Can stress imaging help avoid the need for a coronary angiogram in certain very elderly patients after a heart attack? Our study shows that this strategy allows approximately two out of three patients to avoid a coronary angiography and significantly reduces complications associated with invasive procedures. However, the non-inferiority of the image-guided strategy was not demonstrated with the predefined threshold of 1.24. Therefore, when the invasive strategy is clinically feasible, coronary angiography should not be replaced by a stress imaging strategy used as a “gatekeeper.” These results provide new data to help move toward more individualized care for very elderly patients. » explains Prof. Gilles Barone-Rochette, principal investigator of the EVAOLD trial, member of the FACT/F-CRIN network, and professor of cardiology at Grenoble Alpes University Hospital.
EVAOLD: Key Findings
- The non-inferiority of the image-guided strategy was not demonstrated for the composite endpoint of death, myocardial infarction, or stroke at 1 year: HR 1.22 (95% CI 0.86–1.72), with a non-inferiority margin set at 1.24.
- Only 1 in 3 patients underwent coronary angiography with the image-guided strategy: 31.9% of patients underwent the procedure compared to 99% with the systematic invasive strategy.
- Fewer than one-fourth as many patients experienced complications related to invasive procedures: 2.1% versus 9.3%.
- Fewer patients required revascularization: 22.3% versus 55.5%.
- 572 patients aged 80 and older, with a mean age of 85.7 years, were analyzed at 25 French centers.
- In elderly patients with NSTEMI, when an invasive strategy is clinically feasible, coronary angiography should not be replaced by a strategy using stress imaging as a “gatekeeper.”
The FACT (French Alliance for Cardiovascular Clinical Trials) network is the national clinical research network dedicated to cardiovascular diseases, particularly coronary artery disease, atherothrombosis, and the cardiovascular complications of diabetes. Established in 2012 and designated an F-CRIN network of excellence in 2014, its mission is to promote, organize, and strengthen clinical research in these areas of critical public health importance. The network is coordinated by Professors Philippe Gabriel Steg (AP-HP, Bichat Hospital), Tabassome Simon (AP-HP, Saint Antoine Hospital), and Gilles Lemesle (Lille University Hospital), and is supported by a scientific and operational governance structure bringing together experts in cardiovascular clinical research from nearly 31 research centers across the country. For more information: https://www.fcrin.org/fact
F-CRIN is a national clinical research infrastructure created in 2012, led by Inserm in partnership with hospitals, healthcare companies, and universities, and supported by the National Research Agency and the Ministry of Health. Its mission is to strengthen the competitiveness of French clinical research by fostering a collective scientific and operational dynamic that benefits patients and drives innovation in healthcare. To achieve this, F-CRIN relies on three pillars: bringing together clinical research stakeholders; developing professionals’ expertise by pooling know-how, resources, and capabilities; and accelerating the adoption of new practices and the development of new therapeutic solutions. F-CRIN operates under a federative model that is unique in Europe, currently bringing together 29 complementary components dedicated to clinical research in France: 27 accredited clinical research networks and platforms, 1 national coordination unit, and 1 support platform for the design and conduct of clinical trials. With more than 2,000 professionals pooling their expertise and resources, F-CRIN also serves as the French interface for the European clinical research network ECRIN, promoting the participation of French teams and centers in multinational clinical trials. More information: https://www.fcrin.org
With a staff of 11,500 professionals, the Grenoble Alpes University Hospital (CHUGA) provides comprehensive specialized and community-based care for the entire region. Excelling in a wide range of disciplines and equipped with state-of-the-art technology, the CHUGA boasts numerous areas of excellence, both in medical and surgical care and in research. It treats numerous patients each year and provides both routine and highly specialized medical and surgical care. To shape the future of healthcare in the 21st century, the Grenoble Alpes University Hospital is reinventing itself by focusing on cross-disciplinary training for all its professionals, developing innovative projects, and driving digital and environmental transformations. The Grenoble Alpes University Hospital comprises four main sites, including the Couple Enfant Hospital, which specializes in pediatrics, obstetrics, gynecology, and assisted reproduction.
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