Laurent Bonello1, Marc Laine2, Etienne Puymirat3, Gilles Lemesle4, Franck Thuny2, Franck Paganelli5, Pierre Michelet6, Antoine Roch7, François Kerbaul8, Laurent Boyer9. 1. Service de Cardiologie, Centre Hospitalier Universitaire de Marseille, Hôpital Nord, Aix-Marseille Université, Marseille, France; Aix-Marseille Université, INSERM UMR-S 1076, Vascular Research Center of Marseille, Marseille, France; MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France. Electronic address: laurentbonello@yahoo.fr. 2. Service de Cardiologie, Centre Hospitalier Universitaire de Marseille, Hôpital Nord, Aix-Marseille Université, Marseille, France; MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France. 3. Département de Cardiologie, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris, Paris, France; Université Paris Descartes, INSERM U-970, Paris, France. 4. Service d'Accueil des Urgences, Hôpital Timone, Marseille, France. 5. Service de Cardiologie, Centre Hospitalier Universitaire de Marseille, Hôpital Nord, Aix-Marseille Université, Marseille, France. 6. MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France; Département de Cardiologie, CHU de Lille, Lille, France. 7. MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France; Service d'Accueil des Urgence, Hôpital Nord, Marseille, France. 8. MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France; Pole RUSH, Assistance-Publique Hôpitaux de Marseille, Marseille, France. 9. EA 3279-Public Health, Chronic Diseases and Quality of Life-Research Unit, Aix-Marseille University, Marseille, France.
Abstract
OBJECTIVES: The aim of this study was to compare an early versus a delayed invasive strategy in non-ST-segment elevation acute coronary syndromes by performing a meta-analysis of all available randomized controlled clinical trials. BACKGROUND: An invasive approach is recommended to prevent death and myocardial infarction in non-ST-segment elevation acute coronary syndromes. However, the timing of angiography and the subsequent intervention, when required, remains controversial. METHODS: A previous meta-analysis of 7 randomized clinical trials comparing early and delayed invasive strategies in non-ST-segment elevation acute coronary syndromes with 3 new randomized clinical trials identified in a search of the published research (n = 10 trials, n = 6,397 patients) was updated. RESULTS: The median time between randomization and angiography ranged from 0.5 to 14.0 h in the early group and from 18.3 to 86.0 h in the delayed group. There was no difference in the primary endpoint of mortality (4% vs. 4.7%; random-effects odds ratio [OR]: 0.85; 95% confidence interval [CI]: 0.67 to 1.09; p = 0.20; I2 = 0%). The rate of myocardial infarction was also similar (6.7% vs. 7.7%; random-effects OR: 0.88; 95% CI: 0.53 to 1.45; p = 0.62; I2 = 77.5%). An early strategy was associated with a reduction in recurrent ischemia or refractory angina (3.8% vs. 5.8%; random-effects OR: 0.54; 95% CI: 0.40 to 0.74; p < 0.01; I2 = 28%) and a shorter in-hospital stay (median 112 h [interquartile range: 61 to 158 h] vs. 168 h [interquartile range: 90.3 to 192 h]; random-effects standardized mean difference -0.40; 95% CI: -0.59 to -0.21; p < 0.01; I2 = 79%). Major bleeding was similar in the 2 groups (3.9% vs. 4.2%; random-effects OR: 0.94; 95% CI: 0.73 to 1.22; p = 0.64; I2 = 0%). CONCLUSIONS: An early invasive strategy does not reduce the risk for death or myocardial infarction compared with a delayed strategy. Recurrent ischemia and length of stay were significantly reduced with an early invasive strategy.
OBJECTIVES: The aim of this study was to compare an early versus a delayed invasive strategy in non-ST-segment elevation acute coronary syndromes by performing a meta-analysis of all available randomized controlled clinical trials. BACKGROUND: An invasive approach is recommended to prevent death and myocardial infarction in non-ST-segment elevation acute coronary syndromes. However, the timing of angiography and the subsequent intervention, when required, remains controversial. METHODS: A previous meta-analysis of 7 randomized clinical trials comparing early and delayed invasive strategies in non-ST-segment elevation acute coronary syndromes with 3 new randomized clinical trials identified in a search of the published research (n = 10 trials, n = 6,397 patients) was updated. RESULTS: The median time between randomization and angiography ranged from 0.5 to 14.0 h in the early group and from 18.3 to 86.0 h in the delayed group. There was no difference in the primary endpoint of mortality (4% vs. 4.7%; random-effects odds ratio [OR]: 0.85; 95% confidence interval [CI]: 0.67 to 1.09; p = 0.20; I2 = 0%). The rate of myocardial infarction was also similar (6.7% vs. 7.7%; random-effects OR: 0.88; 95% CI: 0.53 to 1.45; p = 0.62; I2 = 77.5%). An early strategy was associated with a reduction in recurrent ischemia or refractory angina (3.8% vs. 5.8%; random-effects OR: 0.54; 95% CI: 0.40 to 0.74; p < 0.01; I2 = 28%) and a shorter in-hospital stay (median 112 h [interquartile range: 61 to 158 h] vs. 168 h [interquartile range: 90.3 to 192 h]; random-effects standardized mean difference -0.40; 95% CI: -0.59 to -0.21; p < 0.01; I2 = 79%). Major bleeding was similar in the 2 groups (3.9% vs. 4.2%; random-effects OR: 0.94; 95% CI: 0.73 to 1.22; p = 0.64; I2 = 0%). CONCLUSIONS: An early invasive strategy does not reduce the risk for death or myocardial infarction compared with a delayed strategy. Recurrent ischemia and length of stay were significantly reduced with an early invasive strategy.
Authors: Eliano P Navarese; Bernhard Wernly; Michael Lichtenauer; Martino Pepe; Wojciech Wanha; Giuseppe Ferrante; Lara Frediani; Verena Veulemans; Tobias Zeus; Ralf Westenfeld; Christian Jung; Paul A Gurbel Journal: J Thorac Dis Date: 2018-01 Impact factor: 2.895
Authors: Erik A Badings; Wouter S Remkes; Salem H K The; Jan-Henk E Dambrink; Geert Tjeerdsma; Saman Rasoul; Jorik R Timmer; Marloes L J van der Wielen; Dirk J A Lok; Renicus S Hermanides; Jan Van Wijngaarden; Harry Suryapranata; Arnoud W J van 't Hof Journal: Open Heart Date: 2017-03-02
Authors: Ajay K Gupta; Hani Jneid; Daniel Addison; Hossein Ardehali; Amelia K Boehme; Sanket Borgaonkar; Romain Boulestreau; Kevin Clerkin; Nicolas Delarche; Holli A DeVon; Isabella M Grumbach; Jose Gutierrez; Daniel A Jones; Vikas Kapil; Carmela Maniero; Amgad Mentias; Pamela S Miller; Sher May Ng; Jai D Parekh; Reynaldo H Sanchez; Konrad Teodor Sawicki; Anneline S J M Te Riele; Carol Ann Remme; Barry London Journal: J Am Heart Assoc Date: 2020-04-29 Impact factor: 5.501