Routine invasive versus selective invasive strategies for Non‐ST‐elevation acute coronary syndromes: An Updated meta‐analysis of randomized trials

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.