Early Invasion Strategy May Be A Therapeutic Option For Patients With Non-ST Segment Elevation Acute Coronary Syndrome

Background and objectives:An invasive approach is recommended as the treatment method of patients with non-ST elevated acute coronary syndromes(NSTE-ACS).There are inconsistent conclusions about the prognosis of patients in previous randomized controlled trials or observational studies on early and delayed routine intervention strategies.Because the heterogeneity in the previous study was simultaneously significant among NSTE-ACS patients and the time of the follow up was too short,the optimal time for intervention in patients with NSTE-ACS is unclear.This study was designed to ascertain the optimal time and compare the effect of early and delayed coronary artery invasive strategies on short-medium term prognosis in patients with NSTE-ACS.Methods:Pubmed,Cochrane Library,Embase were searched by compute up to December-30-2018.Randomized controlled trials(RCTs)comparing an early versus a delayed coronary artery invasive strategy in patients with NSTE-ACS were included.The primary endpoint(death and recurrent myocardial infarction)and secondary endpoints(major bleeding and recurrent revascularization),as well as composite endpoint(death,recurrent myocardial infarction and myocardial ischemia)were included.After the evaluation of the quality of the literature,the data were divided into two categorical variables,and the heterogeneity between the studies was evaluated by I~2.Finally,fixed or random-effected meta-analysis with software RevMan 5.3 version was applied for data analysis.Results:A total of 6 RCTs involving 4,277 patients with NSTE-ACS were included in the meta-analysis.Among them,the early coronary artery invasive strategy was performed for 2,224 patients and the delayed coronary artery invasive strategy was performed for 2,053 patients.Time to coronary angiography varied from0.5 to 24 h in the early coronary artery invasive strategy and from 18.6 to 72 h in the delayed coronary artery invasive strategy.There was a statistical difference in the primary endpoints of death among patients with NSTE-ACS between early and delayed coronary artery invasive strategies(4.6%vs 6%;OR:0.76;95%CI:0.58 to0.99;P=0.04;I~2=0%),but not for recurrent myocardial infarction(6.0%vs 6.3%;OR:0.94;95%CI:0.73 to 1.21;P=0.64;I~2=60%).The major bleeding in patients with NSTE-ACS was similar between both strategies(2.7%vs 3.1%;OR:0.88;95%CI:0.59 to 1.31;P=0.54;I~2=0%).However,the composite endpoints in the early coronary artery invasive strategy patients with NSTE-ACS was significantly lower than that of the delayed coronary artery invasive strategy(10.9%vs 13.9%;OR:0.76;95%CI:0.63 to 0.92;P=0.006;I~2=0%),and the recurrent revascularization between both strategies were just the opposite(8.7%vs 5.9%;OR:1.5;95%CI:1.15 to 1.97;P=0.003;I~2=0%).Conclusions:The systematic review and meta-analysis demonstrates that the early coronary artery invasive strategy had a beneficial trend on death and significantly reduced the composite endpoint in patients with NSTE-ACS,but increased the rate of revascularization.For recurrent myocardial infarction and major bleeding,there was no statistical difference between the two coronary artery invasion strategies.Namely,the early coronary artery invasive strategy can be used for the treatment of patients with NSTE-ACS,but the only disadvantage is that it can easily increase the incidence of revascularization.The randomized controlled studies are required to further elucidate the clinical benefits of the two interventional strategies.