Comparison Of Early Invasive And Conservative Strategies In Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: A Meta-Analysis Of Randomized Trials

Objective:Patients with NSTE-ACS can be treated with a routine invasive strategy involving early angiography and revascularization or a conservative way with selective invasive strategy only if medical therapy failed or substantial residual ischemia was documented. We conduct this meta-analysis of the different outcomes from the RCTs to compare the benefits and risks of the two strategies.Methods:We search randomized trials from PubMed, Embase, Cochrane databases, and also hand searching of bibliographies of relevant studies as well as review articles. Two investigators independently reviewed all identified studies to determine which trials were avalible for the inclusion criteria. Finally extract needed data from each trial. Statistical analysis is performed using the software STATA version 10.0.Results:A total of ten trials were eligible for the meta-analysis. During the initial hospitalization, death occurred in 92 (1.73%) of 5330 patients in the routine invasive (RI) group compared with 64 (1.20%) of 5318 in the selective invasive group (RR,1.42; 95%CI,1.04-1.95). There was a nonsignificant trend toward fewer MI (4.6% vs 3.3%; RR,1.30; 95%CI, 0.87-1.93) and also a nonsignificant reduction in the composite of death or MI (6.0% vs 4.3%; RR,1.30; 95% CI,0.91-1.87). At the end of follow-up, in total,355 (6.7%) of 5330 patients in the routine invasive group died compared with 385 (7.2%) of 5318 in the selective invasive group (RR,0.92; 95%CI,0.80-1.06). There was a significant 22% increase in myocardial infarction (8.6% vs 11.0%; RR,0.78; 95%CI,0.70-0.88),and also a significant increase in death or MI (13.9%vs 16.3%; RR,0.85; 95% CI,0.78-0.93). There was a significant reduction in rehospitalizations with a routine invasive strategy (29.6% vs 37.7% for routine vs selective, respectively; RR,0.81; 95%CI,0.71-0.93).Conclusion:An RI strategy reduces longterm rates of MI and the composite of death or MI in patients with unstable angina and NSTEMI. However, during initial hospitalization, a routine invasive strategy has a significant trend toward more deaths. We would attach further studies to optimal timing of angiography, best adjuctive medince around PCI, and timely risk stratification.