Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era
- 31 December 2009
- reference entry
- review article
- Published by Wiley
- No. 3,p. CD004815
- https://doi.org/10.1002/14651858.CD004815.pub3
Abstract
Background In patients with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) two strategies are possible, either a routine invasive strategy where all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularization; or a conservative strategy where medical therapy alone is used initially, with selection of patients for angiography based on clinical symptoms or investigational evidence of persistent myocardial ischemia. Objectives To determine the benefits of an invasive compared to conservative strategy for treating UA/NSTEMI in the stent era. Search strategy The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE and EMBASE were searched (1996 to February 2008) with no language restrictions. Selection criteria Included studies were prospective trials comparing invasive with conservative strategies in UA/NSTEMI. Data collection and analysis We identified five studies (7818 participants). Using intention-to-treat analysis with random-effects models, summary estimates of relative risk (RR) with 95% confidence interval (CI) were determined for primary end-points of all-cause death, fatal and non-fatal myocardial infarction, all-cause death or non-fatal myocardial infarction, and refractory angina. Further analysis of included studies was undertaken based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. Heterogeneity was assessed using Chi(2) and variance (I-2 statistic) methods. Main results In the all-study analysis, mortality during initial hospitalization showed a trend to hazard with an invasive strategy (RR 1.59, 95% CI 0.96 to 2.64). The invasive strategy did not reduce death on longer-term follow up. Myocardial infarction rates assessed at 6 to 12 months (5 trials) and 3 to 5 years (3 trials) were significantly decreased by an invasive strategy (RR 0.73, 95% CI 0.62 to 0.86; and RR 0.78, 95% CI 0.67 to 0.92 respectively). The incidence of early (< 4 month) and intermediate (6 to 12 month) refractory angina were both significantly decreased by an invasive strategy (RR 0.47, 95% CI 0.32 to 0.68; and RR 0.67, 95% CI 0.55 to 0.83 respectively), as were early and intermediate rehospitalization rates (RR 0.60, 95% CI 0.41 to 0.88; and RR 0.67, 95% CI 0.61 to 0.74 respectively). The invasive strategy was associated with a two-fold increase in the RR of peri-procedural myocardial infarction (as variably defined) and a 1.7-fold increase in the RR of (minor) bleeding with no hazard of stroke. Authors' conclusions Compared to a conservative strategy for UA/NSTEMI, an invasive strategy is associated with reduced rates of refractory angina and rehospitalization in the shorter term and myocardial infarction in the longer term. However, the invasive strategy is associated with a doubled risk of procedure-related heart attack and increased risk of bleeding and procedural biomarker leaks. Available data suggest that an invasive strategy may be particularly useful in those at high risk for recurrent events.Keywords
This publication has 144 references indexed in Scilit:
- Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE)BMJ, 2006
- Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE)Heart, 2005
- Health-related quality of life after interventional or conservative strategy in patients with unstable angina or non–ST-segment elevation myocardial infarction: One-year results of the third randomized intervention trial of unstable angina (RITA-3)Journal of the American College of Cardiology, 2005
- A Validated Prediction Model for All Forms of Acute Coronary SyndromeJAMA, 2004
- Measuring inconsistency in meta-analysesBMJ, 2003
- Diltiazem and Reinfarction in Patients with Non-Q-Wave Myocardial InfarctionNew England Journal of Medicine, 1986
- Coronary Arteriographic Findings Soon after Non-Q-Wave Myocardial InfarctionNew England Journal of Medicine, 1986
- Aspirin, Sulfinpyrazone, or Both in Unstable AnginaNew England Journal of Medicine, 1985
- Protective Effects of Aspirin against Acute Myocardial Infarction and Death in Men with Unstable AnginaNew England Journal of Medicine, 1983
- Prevalence of Total Coronary Occlusion during the Early Hours of Transmural Myocardial InfarctionNew England Journal of Medicine, 1980