Key result
A routine early invasive strategy significantly reduced the composite of all-cause mortality and recurrent non-fatal myocardial infarction by 21% (RR 0.79) compared to a conservative strategy in patients with UA/NSTEMI.
Why the study?
Does a routine early invasive strategy reduce all-cause mortality and recurrent non-fatal MI in patients with UA/NSTEMI compared to a conservative strategy?
Meta-Analysis (n=10,412)
Does a routine early invasive strategy reduce all-cause mortality and recurrent non-fatal MI in patients with UA/NSTEMI compared to a conservative strategy?
A routine early invasive strategy reduces long-term death and MI in patients with unstable angina, but does not show the same benefit and may increase short-term risk in patients with NSTEMI.
Supports routine early invasive strategy in UA/NSTEMI; confirms long-term reduction in death/MI.
Randomized controlled trials (RCTs) were conflicting to support whether unstable angina versus non-ST-elevation myocardial infarction (UA/NSTEMI) patients best undergo early invasive or a conservative revascularization strategy. RCTs with cardiac biomarkers, in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from 1975-2013 were reviewed considering all cause mortality, recurrent non-fatal myocardial infarction (MI) and their combination. Follow-up lasted from 6-24 months and the use of routine invasive strategy up to its end was associated with a significantly lower composite of all-cause mortality and recurrent non-fatal MI (Relative Risk [RR] 0.79; 95% confidence interval [CI], 0.70-0.90) in UA/NSTEMI. In NSTEMI, by the invasive strategy, there was no benefit (RR 1.19; 95% CI, 1.03-1.38). In the shorter time period, from randomization to discharge, a routine invasive strategy was associated with significantly higher odds of the combined end-point among UA/NSTEMI (RR 1.29; 95% CI, 1.05-1.58) and NSTEMI (RR 1.82; 95% CI, 1.34-2.48) patients. Therefore, in trials recruiting a large number of UA patients, by routine invasive strategy the largest benefit was seen, whereas in NSTEMI patients death and non-fatal MI were not lowered. Routine invasive treatment in UA patients is accordingly supported by the present study.
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Manfrini et al. (2016) conducted a meta-analysis in Unstable angina and non-ST-elevation myocardial infarction (UA/NSTEMI) (n=10,412). Routine early invasive strategy vs. Conservative or selective invasive strategy was evaluated on Composite of all-cause mortality and recurrent non-fatal myocardial infarction in UA/NSTEMI patients at end of follow-up (RR 0.79, 95% CI 0.70-0.90). A routine early invasive strategy significantly reduced the composite of all-cause mortality and recurrent non-fatal myocardial infarction by 21% (RR 0.79) compared to a conservative strategy in patients with UA/NSTEMI.
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