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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.

View larger version (9K): [in this window] [in a new window] [Download PPT slide]   Figure 1 Relative risk of all-cause mortality for early invasive therapy compared with conservative therapy at a mean follow-up of 2 years. The results show a long-term survival benefit from early invasive therapy. 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; RITA-3 = Randomized Intervention Trial of Unstable Angina; RR = relative risk; TIMI-18 = Thrombolysis In Myocardial Infarction-18; 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.

View larger version (9K): [in this window] [in a new window] [Download PPT slide]   Figure 2 Relative risk of all-cause mortality for early invasive therapy compared with conservative therapy as a function of time. The results show a long-term survival benefit from early invasive therapy without an increase in early adverse events.

View larger version (9K): [in this window] [in a new window] [Download PPT slide]   Figure 3 Relative risk of all-cause mortality based on time of angiography and the extent of revascularization. The results show that invasive therapy at a median of 9.3 h does not provide a greater survival advantage compared with angiography at a median of 39.4 h. In contrast, when a large proportion of invasively treated patients relative to conservatively treated patients undergo revascularization by follow-up, there is a strong improvement in late survival.

View larger version (9K): [in this window] [in a new window] [Download PPT slide]   Figure 4 Relative risk of recurrent nonfatal myocardial infarction for early invasive therapy compared with conservative therapy at a mean follow-up of 2 years. The results show a long-term reduction in myocardial infarction from early invasive therapy. Abbreviations as in Figure 1.

View larger version (8K): [in this window] [in a new window] [Download PPT slide]   Figure 5 Relative risk of recurrent unstable angina resulting in rehospitalization for early invasive therapy compared with conservative therapy at a mean follow-up of 13 months. The results show a long-term reduction in recurrent unstable angina from early invasive therapy. Abbreviations as in Figure 1.