Key result
Early invasive strategy in NSTE-ACS fails to reduce mortality vs delayed strategy but cuts recurrent ischemia.
Why the study?
The optimal timing of an invasive strategy in NSTE-ACS remains controversial, and recent RCTs and long-term follow-up data had not yet been incorporated into a contemporary meta-analysis.
Does an early invasive strategy reduce all-cause mortality in patients with NSTE-ACS compared to a delayed invasive strategy?
Meta-Analysis (n=10,209)
Does an early invasive strategy reduce all-cause mortality in patients with NSTE-ACS compared to a delayed invasive strategy?
In patients with NSTE-ACS, an early invasive strategy does not reduce mortality or MI compared to a delayed strategy, but it does reduce recurrent ischemia and hospital length of stay.
Supports risk-stratified delayed invasive strategy in NSTE-ACS; confirms no mortality or MI reduction despite less recurrent ischemia.
AIMS: The optimal timing of an invasive strategy (IS) in non-ST-elevation acute coronary syndrome (NSTE-ACS) is controversial. Recent randomized controlled trials (RCTs) and long-term follow-up data have yet to be included in a contemporary meta-analysis. METHODS AND RESULTS: A systematic review of RCTs that compared an early IS vs. delayed IS for NSTE-ACS was conducted by searching MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. A meta-analysis was performed by pooling relative risks (RRs) using a random-effects model. The primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction (MI), recurrent ischaemia, admission for heart failure (HF), repeat re-vascularization, major bleeding, stroke, and length of hospital stay. This study was registered with PROSPERO (CRD42021246131). Seventeen RCTs with outcome data from 10 209 patients were included. No significant differences in risk for all-cause mortality [RR: 0.90, 95% confidence interval (CI): 0.78-1.04], MI (RR: 0.86, 95% CI: 0.63-1.16), admission for HF (RR: 0.66, 95% CI: 0.43-1.03), repeat re-vascularization (RR: 1.04, 95% CI: 0.88-1.23), major bleeding (RR: 0.86, 95% CI: 0.68-1.09), or stroke (RR: 0.95, 95% CI: 0.59-1.54) were observed. Recurrent ischaemia (RR: 0.57, 95% CI: 0.40-0.81) and length of stay (median difference: -22 h, 95% CI: -36.7 to -7.5 h) were reduced with an early IS. CONCLUSION: In all-comers with NSTE-ACS, an early IS does not reduce all-cause mortality, MI, admission for HF, repeat re-vascularization, or increase major bleeding or stroke when compared with a delayed IS. Risk of recurrent ischaemia and length of stay are significantly reduced with an early IS.
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Kite et al. (2022) conducted a meta-analysis in non-ST-elevation acute coronary syndrome (NSTE-ACS) (n=10,209). Early invasive strategy vs. Delayed invasive strategy was evaluated on All-cause mortality (RR 0.90, 95% CI 0.78-1.04). An early invasive strategy in NSTE-ACS did not significantly reduce all-cause mortality compared with a delayed strategy (RR 0.90; 95% CI 0.78-1.04), but did reduce recurrent ischaemia.
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