Author + information
- 1Newark Beth Israel Medical Center, Newark, New Jersey, United States
- 2Rutgers New Jersey Medical School, Newark, New Jersey, United States
- 3St Luke’s University Hospital, Bethlehem, Pennsylvania, USA, Allentown, Pennsylvania, United States
- 4Lehigh Valley Hospital, Allentown, Pennsylvania, United States
Current guidelines suggest an early invasive strategy (EIS) over an initial conservative strategy (ICS) in non-ST elevation acute coronary syndrome (NSTE-ACS), particularly for high-risk patients. However, individual randomized controlled trials (RCTs) have shown contrasting results and a definite evidence for the impact of EIS on mortality is lacking. Further, it remains unknown if benefit of EIS vs. ICS persists over long-term. Therefore, we conducted a meta-analysis to compare EI and IC strategies in patients with NSTE-ACS at intermediate and long term follow-ups.
A systematic review of RCTs in MEDLINE, EMBASE, CINAHL, and Cochrane databases comparing early invasive with initial conservative strategy for patients with NSTE-ACS was performed. Random effects meta-analysis was conducted to estimate risk ratio (RR) with 95% confidence intervals (CI) for several end-points.
A total of 14 studies with 10,786 patients were included in the cumulative analysis at 0.5-2 years follow up. Compared to an ICS, EIS was associated with significantly decreased risk of all cause death [RR 0.86; 95% 0.75-0.99], MI [0.79; 0.66-0.94], and rehospitalization due to coronary event [0.73; 0.60-0.90]. Risk of major bleeding was higher with EIS compared to an ICS [2.05; 1.49-2.82]. At longer term follow-up (10-15 years), there was no statistical difference between the two groups in terms of all-cause mortality [1.01; 0.93-1.09]. An EIS should be considered a preferred approach for most patients with NSTE-ACS. Further studies are needed to identify specific sub-groups who might have longer-term benefit with an EIS compared to ICS.
An EIS should be considered a preferred approach for most patients with NSTE-ACS. Further studies are needed to identify specific sub-groups who might have longer-term benefit with an EIS compared to ICS.
CORONARY: Acute Coronary Syndromes