Early Invasive Vs Initial Conservative Strategy In Non-ST-segment Elevation Acute Coronary Syndromes:10 Most Prognostic Factors Decreasing The Hazard To Getting The Benefits With Early Invasive Strategy

Background There is debate about routine early invasive treatment compared with conservative treatment in non-ST-segment elevation acute coronary syndromes(NSTE-ACS).Current guidelines recommend an early invasive approach in high-risk patients with acute coronary syndromes without ST-segment elevation.Previously,there have been ten trials which randomized approximately 10,000 NSTE-ACS patients into an early invasive or conservative treatment strategy.In these trials,early invasive treatment was not associated with a reduction in mortality after 1 year of follow-up.However,early invasive treatment was associated with a statistically significant reduction in the composite endpoint of death or nonfatal myocardial infarction compared to conservative treatment.In addition,rehospitalization and refractory angina were less frequent in the early invasive strategy groups.Although the optimal timing of angiography and subsequent revascularization,if appropriate,remains controversial.Our opinion is that these results are massively apparently conflicting only!!.In actual there are many factors deeply responsible for this,like different study designs,inclusion criteria,co-morbidities,treatment ratio between both arms / treatment overlapping,variations in administration of drugs in both groups,PCI ratio between both arms with choice of the Stent and Peri-procedural or long term complications mainly because of approaching-methods,choice of drugs,lack of individualised patient assessment,risk assessment etc.And we believe that with the better understanding of some prognostic and influential factors related to the approach of early invasive strategy,for patients with NSTE-ACS,an early invasive strategy should be strongly considered during initial hospitalisation in all-risk-level patients and in cases of medical therapy failure to reduce angina symptoms and rehospitalization,without increased risk of death or myocardial infarction.Objectives Aims to:(1)Review the literature for best initial management approach for Non-STElevated Acute Coronary Syndromes(NSTE-ACS),(2)Minimise the Conflicting Strength with the better understanding of Heterogeneity or Differences between the Trials and Meta-analyses,(3)To collect the relevant Mega-data for a specific topic,our is early invasive strategy or initial conservative strategy;what strategy is best as initial management for NSTE-ACS?,(4)Evaluation of the most Prognostic and Influential factors for the early invasive approach,(5)Posit directions for future research.Methods We conducted a computer-based search in representative databases by Medline,Embase,Cochrane database and Google Scholar from 1985 to 2017 using key words of relevant subject headings for randomized controlled trials,meta-analyses and included some standard observational studies that met eligibility criteria for each mentioned topic of our research included10 influential factors headings.We independently reviewed searches and selected trials that compared early invasive strategy with initial conservative strategy covered many dimensions of our research requirements with prognostic values.And also selected many studies for our 10 most influential factors for the early invasive approach in NSTE-ACS.Results We screened more than 500 abstracts,evaluated more than 200 full-text articles.By which included more than 300 Randomised Control Trials and their Meta-Analyses with more than 300 observational but standard studies.As per theme of our type of research,we have collected vast data to cover the almost all aspects of our topic related issues or factors.We corresponded with experts in the field,After focus studying,opinions and discussions with researchers,we extracted and evaluated that there are some influential and prognostic factors regarding early invasive approach for NSTE-ACS patients,which have to be understand,dealing and approach first for the cause of better outcome with early invasive strategy.These most influential factors are:(1)Diagnosis Accuracy(2)Significance of Early Risk Stratification(3)Individualised Patient Assessment: Co-Morbidities(Age Factor,DM,CKD,Gender,HTN,etc)(4)Timing of EIS(5)Radial vs Femoral Approach(6)Prognostic Value of Peri-Procedural and Long-term Drugs(7)Peri-Procedural Major Bleeding(8)Peri-Procedural and Spontaneous MI(9)Stent Type with two Major Complications: Stent Thrombosis & Stent Re-Stenosis and(10)Peri-Procedural Kidney Injury All these 10 factors are most influential,for the choice of EIS,in respect to short and long term mortality benefits,so the evaluation of these factors first,is very vital for the understanding of heterogeneity and differences between the trials.And by applying these,we can reduce the hazard and get the more benefits with EIS in NSTE-ACS patients.Conclusions1.In respect to early invasive strategy for the management of NSTE-ACS,with proper diagnosis,better early risk stratification approach,skilful individualise patient assessment,through proper-site approach,with better understanding of the individualized timing for patients,with administration of proper and recommended pre-and-post procedures,short & long term drugs,and especially the choice and type of stents according to patient co-morbidities,anatomical lesion and clinical condition,we can reduce the mortality hazard complications like peri-procedural major bleeding,peri-procedural &spontaneous MIs,procedural-induced AKI,stent thrombosis and in-stent re-stenosis,all these leads to decreasing mortality indirectly.2.With the better understanding of some prognostic and influential factors related to the approach of early invasive strategy,for patients with NSTE-ACS,an early invasive strategy should be strongly considered during initial hospitalisation in all-risk-level patients.Implications2.New trials designs might be followed under the light of this type of research in respect to decreasing the heterogeneity and the better understanding between the differences of trials results for the sake to get more clarity in the trial results.3.This type of new vast-data based research,although dealing with only one conflicting issue but covered almost all related topics,should be planned for(a)previously long-time conflicting issues due to the heterogeneity among the results of relevant trials,for the sake of better understanding of the causative factors responsible for heterogeneity between the trials,(b)and improve knowledge with addition of the newly or updatedevidence based studies to cover for almost all dimensions of the conflicting issue.