Highlights
- •RCTs produced conflicting results on effects of early invasive strategy in NSTE-ACS.
- •Pooled data analysis showed reduction in recurrent ischemia and no mortality benefit.
- •There is high between-study heterogeneity in the reported rates of new MI.
- •Heterogeneity stems from ambiguous new MI definition and early intervention timing.
- •Impact of timing on new MI rates is stronger in studies with higher PCI rates.
Abstract
Background
Previous randomized controlled trials (RCTs) have produced conflicting results on
the effects of early versus delayed invasive strategy in NSTE-ACS patients.
Objectives
To perform up to date meta-analysis on the pooled data sample comparing early versus
delayed invasive strategy, and to explore potential causes for the observed high statistical
heterogeneity.
Methods
MEDLINE via Pubmed, Central, Google Scholar, Clinical Trials Registry, Current controlled
study and ClinicalTrials.gov registry and relevant conference proceedings were searched.
RCTs were included that directly compared early versus delayed invasive strategy and
reported rates of death, new myocardial infarction (MI) and/or recurrent ischemia.
Results
10 RCTs with 6089 patients were included. Time to coronary angiography varied from
0.5 to 24 h in the early and from 20.5 to 86 h in the delayed group. Meta-analysis
showed no significant difference in mortality (OR = 0.83, 95%CI 0.64–1.08, P = 0.16),
and similar new MI rates (OR = 1.02, 95%CI 0.63–1.64, P = 0.94). The rate of recurrent
ischemia was reduced in patients undergoing early coronary angiography (OR = 0.56,
95%CI 0.40–0.79, P = 0.001). Subgroup analysis indicated that the rate of new MI tended
to depend on the study-specific endpoint definition (p for difference between subgroups
0.11), while a meta-regression revealed association of new MI rates with the within-study
delay to coronary angiography (p = 0.05).
Conclusion
Early invasive strategy appears to reduce the occurrence of recurrent ischemia, but
confers no mortality benefit. The true effect on the occurrence of new MI is obscured
by the high between-study heterogeneity that stems mainly from non-uniform timing
of early intervention and new MI definitions across the trials.
Keywords
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Article info
Publication history
Published online: April 30, 2015
Accepted:
April 27,
2015
Received in revised form:
April 21,
2015
Received:
March 10,
2015
Identification
Copyright
© 2015 Elsevier Ireland Ltd. Published by Elsevier Inc. All rights reserved.
