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Timing of Invasive Strategy in Non-ST-Elevation Acute Coronary Syndrome
Quick Takes
- An early invasive strategy does not reduce all-cause mortality, MI, admission for HF, or repeat revascularization when compared with a delayed invasive strategy in NSTE-ACS.
- However, an early invasive strategy reduces risk of recurrent ischemia, even though there is potential of publication bias regarding this outcome, and length of hospital stay.
- Overall, these data confirm that a blanket use of early invasive management of all NSTE-ACS patients is not required.
Study Questions:
What is the optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS)?
Methods:
The investigators conducted a systematic review of randomized controlled trials (RCTs) that compared an early invasive strategy versus a delayed invasive strategy for NSTE-ACS 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 ischemia, admission for heart failure (HF), repeat revascularization, major bleeding, stroke, and length of hospital stay. This study was registered with PROSPERO (CRD42021246131).
Results:
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 revascularization (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 ischemia (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 invasive strategy.
Conclusions:
The authors concluded that among all-comers with NSTE-ACS, an early invasive strategy does not reduce all-cause mortality, MI, admission for HF, repeat revascularization, or increase major bleeding or stroke when compared with a delayed invasive strategy, but risk of recurrent ischemia and length of stay are significantly reduced with an early invasive strategy.
Perspective:
This study-level meta-analysis reports that an early invasive strategy does not reduce all-cause mortality, MI, admission for HF, or repeat revascularization when compared with a delayed invasive strategy in NSTE-ACS. However, an early invasive strategy reduces risk of recurrent ischemia, even though there is potential of publication bias regarding this outcome, and length of hospital stay. Furthermore, safety outcomes of major bleeding and stroke were no different between strategies. The present analysis is subject to the inherent limitations of study-level meta-analyses and does not allow an evaluation of the invasive strategies according to the risk profile of the NSTE-ACS patients. Overall, these data confirm that a blanket use of early invasive strategy of all NSTE-ACS patients is not required. A dedicated RCT comparing an early with a delayed invasive strategy only in high-risk NSTEMI patients or at least an updated patient-level meta-analysis would be helpful to better identify which patients, if any, may benefit from early invasive strategy in the setting of NSTE-ACS.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Interventions and ACS, Interventions and Vascular Medicine, Chronic Angina
Keywords: Acute Coronary Syndrome, Heart Failure, Hemorrhage, Length of Stay, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Non-ST Elevated Myocardial Infarction, Percutaneous Coronary Intervention, Primary Prevention, Risk, Stroke, Vascular Diseases
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