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Review
. 2017 Aug 19;390(10096):737-746.
doi: 10.1016/S0140-6736(17)31490-3. Epub 2017 Aug 1.

Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials

Alexander Jobs  1 , Shamir R Mehta  2 , Gilles Montalescot  3 , Eric Vicaut  3 , Arnoud W J Van't Hof  4 , Erik A Badings  5 , Franz-Josef Neumann  6 , Adnan Kastrati  7 , Alessandro Sciahbasi  8 , Paul-Georges Reuter  9 , Frédéric Lapostolle  9 , Aleksandra Milosevic  10 , Goran Stankovic  11 , Dejan Milasinovic  10 , Reinhard Vonthein  12 , Steffen Desch  1 , Holger Thiele  13
Affiliations
Review

Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials

Alexander Jobs et al. Lancet. .

Abstract

Background: A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality.

Methods: We identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988).

Findings: We included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive.

Interpretation: An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients.

Funding: None.

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