Alexander Jobs1, Shamir R Mehta2, Gilles Montalescot3, Eric Vicaut3, Arnoud W J Van't Hof4, Erik A Badings5, Franz-Josef Neumann6, Adnan Kastrati7, Alessandro Sciahbasi8, Paul-Georges Reuter9, Frédéric Lapostolle9, Aleksandra Milosevic10, Goran Stankovic11, Dejan Milasinovic10, Reinhard Vonthein12, Steffen Desch1, Holger Thiele13. 1. University Heart Center Lübeck, Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine, Lübeck, Germany; German Centre for Cardiovascular Research, Lübeck, Germany. 2. Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada. 3. Sorbonne Université Paris 6, ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpetrière, Institut de Cardiologie, Paris, France. 4. Department of Cardiology, Isala Klinieken, Zwolle, Netherlands; Department of Cardiology Research, Deventer Hospital, Deventer, Netherlands. 5. Department of Cardiology Research, Deventer Hospital, Deventer, Netherlands. 6. Universitäts-Herzzentrum Freiburg-Bad Krozingen, Klinik für Kardiologie und Angiologie II, University of Freiburg, Bad Krozingen, Germany. 7. Deutsches Herzzentrum München, Klinik für Kardiologie, München, Germany. 8. Interventional Cardiology, Sandro Pertini Hospital, ASL RM-2, Rome, Italy. 9. AP-HP, Urgences-Samu 93, Hôpital Avicenne, Université Paris 13, 93000 Bobigny, France; Inserm U942, Université Paris 7-Denis Diderot, Paris, France. 10. Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia. 11. Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia. 12. Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Lübeck, Germany; ZKS Lübeck, Universität zu Lübeck, Lübeck, Germany. 13. Heart Center Leipzig - University of Leipzig, Leipzig, Germany; German Centre for Cardiovascular Research, Lübeck, Germany. Electronic address: holger.thiele@medizin.uni-leipzig.de.
Abstract
BACKGROUND: A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality. METHODS: We identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988). FINDINGS: We included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive. INTERPRETATION: An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients. FUNDING: None.
BACKGROUND: A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality. METHODS: We identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988). FINDINGS: We included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive. INTERPRETATION: An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients. FUNDING: None.
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: Thomas A Kite; Amerjeet S Banning; Andrew Ladwiniec; Chris P Gale; John P Greenwood; Miles Dalby; Rachel Hobson; Shaun Barber; Emma Parker; Colin Berry; Marcus D Flather; Nick Curzen; Adrian P Banning; Gerry P McCann; Anthony H Gershlick Journal: BMJ Open Date: 2022-05-03 Impact factor: 3.006