Long-term benefits of an early invasive management in acute coronary syndromes depend on intracoronary stenting and aggressive antiplatelet treatment: a metaregression.
BACKGROUND
Although recent data support an early invasive management in acute coronary syndromes (ACS), overall evidence appears conflicting. We performed a metaregression to explore the impact of intracoronary stenting and aggressive antiplatelet treatment on the risk/benefit ratio of an early invasive approach.


METHODS
We searched several databases up to March 2004 for randomized trials comparing an early invasive versus delayed invasive or conservative management in ACS. Random-effects odds ratios were computed for death and/or myocardial infarction at the longest follow-up. Log (odds ratios) were tested for interaction with stenting and aggressive antiplatelet treatment (ie, glycoprotein IIb/IIIa inhibitors or thienopyridines in addition to aspirin).


RESULTS
Ten trials (9990 patients, median follow-up 12 months) were pooled. Overall, an early invasive management was associated with significantly reduced rates of death or myocardial infarction (P = .01). Metaregression analysis showed that the 2 most significant predictors of the benefits of an early invasive strategy in patients with ACS on event-free survival were the use, in subjects managed invasively, of aggressive antiplatelet treatment (P = .005) and stenting (P = .011). Moreover, both stenting and aggressive antiplatelet treatment were significantly associated with reduced mortality (respectively, P = .014 and P = .009) and correlated to each other (r = 0.76, P = .010).


CONCLUSIONS
This study shows that the benefits of an early invasive approach in patients with ACS are significantly associated with concomitant aggressive antiplatelet treatment and stenting. These findings thus suggest the overall superiority of an early invasive approach in ACS, as long as state-of-the-art therapies are implemented.
Biondi-Zoccai
Giuseppe G L
GG
Institute of Cardiology, Catholic University, Rome, Italy. gbiondizoccai@tiscali.it
Abbate
Antonio
A
Agostoni
Pierfrancesco
P
Testa
Luca
L
Burzotta
Francesco
F
Lotrionte
Marzia
M
Trani
Carlo
C
Biasucci
Luigi M
LM
D000208:Acute Disease; D000368:Aged; D001241:Aspirin / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D003327:Coronary Disease / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D015201:Meta-Analysis as Topic; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D011743:Pyrimidines / Q000627:therapeutic use; D012044:Regression Analysis; D015607:Stents; D013577:Syndrome
D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011743:Pyrimidines; C476003:thienopyrimidine; D001241:Aspirin