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 ,
Andrew N. Rassi, MD ,
Deepak L. Bhatt, MD* and
Arman T. Askari, MD*,*
* Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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.
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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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