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J Am Coll Cardiol, 2006; 48:1319-1325, doi:10.1016/j.jacc.2006.06.050 (Published online 11 September 2006).
© 2006 by the American College of Cardiology Foundation
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FOCUS ISSUE: CARDIAC INTERVENTION: INTERVENTION IN ACUTE CORONARY SYNDROME

Benefit of Early Invasive Therapy in Acute Coronary Syndromes

A Meta-Analysis of Contemporary Randomized Clinical Trials

Anthony A. Bavry, MD, MPH*, Dharam J. Kumbhani, MD, SM{dagger}, Andrew N. Rassi, MD{ddagger}, Deepak L. Bhatt, MD* and Arman T. Askari, MD*,*

* Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
{dagger} Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
{ddagger} School of Medicine, Case Western Reserve University, Cleveland, Ohio.

Manuscript received April 5, 2006; revised manuscript received May 30, 2006, accepted June 6, 2006.

* Reprint requests and correspondence: Dr. Arman T. Askari, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk F15, Cleveland, Ohio 44195. (Email: askaria2{at}ccf.org).

OBJECTIVES: This study sought to systematically determine whether early invasive therapy improves survival and reduces adverse cardiovascular events in the management of non–ST-segment elevation acute coronary syndromes.

BACKGROUND: Although early invasive therapy reduces recurrent unstable angina, the magnitude of benefit on other important adverse outcomes is unknown.

METHODS: Clinical trials that randomized non–ST-segment elevation acute coronary syndrome patients to early invasive therapy versus a more conservative approach were included for analysis.

RESULTS: In all there were 7 trials with 8,375 patients available for analysis. At a mean follow-up of 2 years, the incidence of all-cause mortality was 4.9% in the early invasive group, compared with 6.5% in the conservative group (risk ratio [RR] = 0.75, 95% confidence interval [CI] 0.63 to 0.90, p = 0.001), and at 1 month (RR = 0.82, 95% CI 0.50 to 1.34, p = 0.43). At 2 years of follow-up, the incidence of nonfatal myocardial infarction was 7.6% in the invasive group, versus 9.1% in the conservative group (RR = 0.83, 95% CI 0.72 to 0.96, p = 0.012), and at 1 month (RR = 0.93, 95% CI 0.73 to 1.19, p = 0.57). At a mean of 13 months of follow-up, there was a reduction in rehospitalization for unstable angina (RR = 0.69, 95% CI 0.65 to 0.74, p < 0.0001).

CONCLUSIONS: Managing non–ST-segment elevation acute coronary syndromes by early invasive therapy improves long-term survival and reduces late myocardial infarction and rehospitalization for unstable angina.

Abbreviations and Acronyms
  CABG = coronary artery bypass grafting
  CI = confidence interval
  FRISC-II = Fragmin and Fast Revascularization During Instability in Coronary Disease
  ICTUS = Invasive Versus Conservative Treatment in Unstable Coronary Syndromes Investigators
  ISAR-COOL = Intracoronary Stenting With Antithrombotic Regimen Cooling Off
  NSTE-ACS = non–ST-segment elevation acute coronary syndrome
  PCI = percutaneous coronary intervention
  RITA-3 = Randomized Intervention Trial of Unstable Angina
  RR = risk ratio
  TACTICS TIMI-18 = Treat Angina With Aggrastat and Determine the Cost of Therapy With an Invasive or Conservative Strategy—Thrombolysis In Myocardial Infarction
  TRUCS = Treatment of Refractory Unstable Angina in Geographically Isolated Areas Without Cardiac Surgery
  VINO = Value of First Day Coronary Angiography/Angioplasty in Evolving Non–ST-Segment Elevation Myocardial Infarction




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