Abstract 4508: Routine vs. Selective Invasive Management and Clinical Outcomes in Non-ST-Segment Elevation Myocardial Infarction or Unstable Angina: A Meta-analysis of Large Randomized Controlled Trials (RCTs)
Background: While 10 RCTs and the recent TIMACS study provide the evidence for current ACC/AHA treatment guidelines advocating an early routine invasive strategy (RIS) for acute coronary syndromes (ACS), some of these trials are small or not optimally blinded.
Objective: We sought to evaluate the benefits and risks of RIS versus a selective invasive strategy (SIS) on short-and long-term clinical outcomes (death or MI) in the treatment of ACS by conducting a meta-analysis of all RCTs with at least 100 patients in each arm.
Methods: We searched Medline, EMBASE and Cochrane databases from 1990 to 2009. Risk ratios (RR) and 95% confidence intervals (CI) were calculated using a random-effects model.
Results: 6 RCTs with a total of 10,081 patients (RIS=5,037 and SIS=5,043) were included. Overall, at an average 33 month follow-up, the incidence of death or MI was similar between RIS vs. SIS (n=811 vs 872; RR, 0.95; 95% CI, 0.78– 1.16; P=0.61). However, during the index hospitalization, death was more common among RIS (n=85 vs. 50; RR=1.66; 95% CI, 1.13–2.44; P=0.01), as was death or MI (n=309 vs. 206; RR=1.51; 95%CI=1.06 –2.13; P=0.02). Post-discharge, RIS was associated with a decrease in both late MI (n=241 vs. 377; RR=0.69; 95% CI, 0.53– 0.9; P=0.007) and death or MI (n=502 vs. 666; RR=0.78; 95% CI=0.64 – 0.96; P=0.02).
Conclusions: While there is late clinical benefit associated with a routine early invasive as compared with selective invasive strategy in ACS patients, this salutary effect may be partially offset by an early hazard of increased in-hospital death or MI. Such a risk-benefit assessment should be carefully considered in all ACS patients.