Routine vs. Selective Invasive Strategies for NSTE-ACS

Study Questions:

What are the outcomes with a routine invasive strategy versus a selective invasive strategy for patients with non–ST-elevation acute coronary syndromes (NSTE-ACS) in the era of stents and antiplatelet therapy?

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 (ORs) 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 nonsignificantly 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).

Conclusions:

The authors concluded that in patients with NSTE-ACS, a routine invasive strategy reduced the risk of ischemic events, including the risk of mortality or MI.

Perspective:

This meta-analysis of 12 randomized trials of patients with NSTE-ACS reports that a routine invasive strategy was associated with a significant reduction in the risk of ischemic events; namely, the composite of all-cause mortality or nonfatal MI primarily due to a reduction in nonfatal MI. There was also a marked reduction in recurrent angina and future revascularization procedures with routine invasive therapy. This contemporary analysis supports current American College of Cardiology/American College of Cardiology, and European Society of Cardiology guidelines, which recommend a routine invasive strategy in the management of high-risk patients with NSTE-ACS, including women and the elderly.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Angina Pectoris, Coronary Angiography, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Platelet Aggregation Inhibitors, Risk, Stents, ESC Congress


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