Timing of Invasive Strategy in Patients with Non-ST Elevation Acute Coronary Syndrome: An Updated Meta-analysis of Randomized Controlled Trials
Tuesday, May 21, 2019
Belmont Ballroom 2-3 (The Cosmopolitan of Las Vegas)
Amit Rout, M.D.
,
Sinai Hospital Of Baltimore, Baltimore, MD
Aakash Garg, MD
,
Newark Beth Israel Medical Center, Newark, NJ
Sahil Agrawal, M.B.B.S.
,
none, Providence, RI
Abhishek Sharma, M.D.
,
Rush University Medical Center, Chicago, IL
John B. Kostis, M.D.
,
Umdnj-robert Wood Johnson Medical School, New Brunswick, NJ
Sunil V. Rao, M.D., FSCAI
,
Duke University Hospital, Durham, NC
Background:
Previous randomized controlled trials (RCTs) have shown conflicting results regarding the optimal timing of invasive strategy in patients with Non-ST segment elevation acute coronary syndrome (NSTE-ACS). We aimed to compare early (EIS) vs delayed (DIS) invasive strategies by performing an updated meta-analysis of all available RCTs. We also analyse the long-term outcomes of these strategies from the available studies.
Methods:
A systematic search of MEDLINE, EMBASE, CINAHL, and Cochrane databases for all the available RCTs comparing EIS vs. DIS in NSTE-ACS population was performed. Two different groups were made: (1) all studies were included, (2) studies with a mean follow up of at least 1 year. Endpoints of interest were all-cause mortality, myocardial infarction, refractory ischemia, and repeat intervention. Random effects meta-analysis was conducted to estimate the odds ratio (OR) with 95% confidence interval (CI) for individual endpoints.
Results:
A total of thirteen studies (n=8715; mean follow up=21 months) were included in the final analysis. EIS was associated with significantly reduced risk of recurrent or refractory ischemia compared to DIS [0.61; 0.40-0.94]. Compared to DIS, there were no significant differences in all-cause mortality [OR 0.89; 95% CI 0.75-1.05] and MI [0.76, 0.55-1.05] in the EIS arm. Seven studies (n=3,932; mean follow up=2.8 years) were included in the long-term follow-up group. In the long-term, there was no significant difference between EIS and DIS in terms of mortality [OR 0.92; 95% 0.75-0.1.13]. However, EIS was associated with significantly reduced risk of recurrent MI [0.72; 0.53-0.98] compared to DIS. On sub-group analysis of the long-term follow-up group, there was a significant reduction in the composite endpoint with EIS in patients with GRACE score>140 [0.75; 0.60-0.94], but not in patients with GRACE score <140 [0.97; 0.56-1.69].
Conclusions:
In all comers with NSTE-ACS, EIS was safe and reduces refractory ischemia without reducing the risk of mortality or MI. While in the long-term, EIS was associated with reduced risk of MI but without any difference in mortality.
