Routine invasive versus selective invasive strategies for Non-ST-elevation acute coronary syndromes: An Updated
Islam Y Elgendy1, Dharam J Kumbhani2, Ahmed N Mahmoud1
1Department of Medicine, University of Florida, Gainesville, Florida.
Insights
A routine invasive strategy for non-ST-elevation acute coronary syndromes (NSTE-ACS) reduces the risk of mortality or myocardial infarction (MI). This approach also lowers recurrent angina and the need for future revascularization procedures.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Conflicting results exist from recent meta-analyses comparing routine versus selective invasive strategies for NSTE-ACS.
- The optimal timing for invasive procedures in NSTE-ACS remains a subject of ongoing research.
Purpose of the Study:
- To conduct an updated systematic review and meta-analysis.
- To compare routine invasive versus selective invasive strategies for NSTE-ACS patients.
- To evaluate outcomes in the era of modern stents and antiplatelet therapies.
Main Methods:
- Systematic search of electronic databases for randomized controlled trials.
- Inclusion of 12 trials involving 9,650 patients.
- Meta-analysis using Peto's model to calculate summary odds ratios.
Main Results:
- A routine invasive strategy significantly reduced the composite of all-cause mortality or myocardial infarction (MI) (OR: 0.86).
- The risk of MI was significantly reduced (OR: 0.78), while all-cause mortality showed a non-significant trend towards reduction (OR: 0.88).
- Routine invasive strategy led to reduced recurrent angina (OR: 0.55) and future revascularization (OR: 0.35).
Conclusions:
- A routine invasive strategy is associated with reduced ischemic events, including mortality or MI, in NSTE-ACS patients.
- This strategy effectively decreases recurrent angina and the need for subsequent revascularization procedures.
- The findings support the use of a routine invasive approach in the current therapeutic landscape for NSTE-ACS.
Objectives:
To perform an updated systematic review comparing a routine invasive strategy with a selective invasive strategy for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) in the era of stents and antiplatelet therapy.
Background:
Recent meta-analyses comparing both strategies have shown conflicting results.
Methods:
Electronic databases were searched for randomized trials that compared a routine invasive strategy (i.e., routine coronary angiography +/- revascularization) versus a selective invasive strategy (i.e., medical stabilization and coronary angiography +/- revascularization if objective evidence of ischemia or refractory ischemia) in patients with NSTE-ACS. Summary odds ratios (OR) were primarily constructed using Peto's model.
Results:
Twelve trials with 9,650 patients were included. Compared with a selective invasive strategy, a routine invasive strategy was associated with a reduction in the composite of all-cause mortality or myocardial infarction (MI) [OR: 0.86, 95% confidence interval (CI) 0.77-0.96] at a mean follow-up of 39 months, primarily due to a reduction in the risk of MI (OR: 0.78, 95% CI: 0.68-0.88). The risk of all-cause mortality was non-significantly reduced with a routine invasive strategy (OR: 0.88, 95% CI: 0.77-1.01). The risk of recurrent angina was reduced with a routine invasive strategy (OR: 0.55, 95% CI: 0.49-0.62), as well as the risk of future revascularization procedures (OR: 0.35, 95% CI: 0.30-0.39).
Conclusion:
In patients with NSTE-ACS, a routine invasive strategy reduced the risk of ischemic events, including the risk of mortality or MI. Routine invasive therapy reduced the risk of recurrent angina and future revascularization procedures. © 2016 Wiley Periodicals, Inc.
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